NSE 211 FINAL EXAM NEWEST 2026 ACTUAL EXAM
TEST BANK| NSE 211 FINAL EXAM REVIEW WITH
COMPLETE 450 REAL EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS/ ALREADY GRADED A+
(BRAND NEW!!)
1. A nurse assesses a patient who had abdominal surgery 3
days ago. The wound edges are well-approximated, and there
is no drainage. The nurse documents this as healing by which
intention?
A. Secondary intention
B. Tertiary intention
C. Primary intention
D. Delayed primary intention
Correct Answer: C. Primary intention
Rationale: Primary intention healing occurs when a wound is
closed surgically with sutures or staples, bringing the edges
together (approximated). This results in minimal scarring and a
lower risk of infection .
2. Which of the following is the defining characteristic of a
Stage 2 pressure injury?
A. Intact skin with non-blanchable erythema
1
,B. Full-thickness tissue loss with visible bone
C. Partial-thickness loss of dermis presenting as a shallow open
ulcer or intact blister
D. Full-thickness tissue loss covered entirely by eschar
Correct Answer: C. Partial-thickness loss of dermis presenting
as a shallow open ulcer or intact blister
Rationale: A Stage 2 pressure injury is characterized by partial-
thickness loss of skin involving the epidermis and dermis. The
wound bed is viable, pink or red, and moist, and may also
present as an intact or ruptured serum-filled blister. It should not
be used to describe moisture-associated skin damage .
3. A patient has a pressure injury on the heel with a wound
bed that is completely covered by black, hard, necrotic tissue.
The nurse classifies this as:
A. Stage 3
B. Stage 4
C. Deep Tissue Injury
D. Unstageable
Correct Answer: D. Unstageable
Rationale: An unstageable pressure injury is defined by full-
thickness tissue loss where the base of the ulcer is covered by
2
,slough (yellow/tan) or eschar (black/brown), obscuring the true
depth. Stable, dry, intact eschar on the heel should not be
removed .
4. What is the recommended maximum angle of head
elevation to prevent shear forces in a patient at risk for
pressure injuries?
A. 15 degrees
B. 30 degrees
C. 45 degrees
D. 60 degrees
Correct Answer: B. 30 degrees
Rationale: Limiting head elevation to 30 degrees (or using a 30-
degree lateral turn position) helps prevent shear. Shear occurs
when the skin remains stationary while the underlying bone and
deep tissues slide downward, stretching and damaging
capillaries .
5. Which tool is specifically designed to assess a patient's risk
for developing pressure injuries by evaluating sensory
perception, moisture, activity, mobility, nutrition, and
friction/shear?
A. Norton Scale
3
, B. Braden Scale
C. Glasgow Coma Scale
D. Morse Fall Scale
Correct Answer: B. Braden Scale
Rationale: The Braden Scale is the most widely used tool for
predicting pressure injury risk. It includes six subscales (sensory
perception, moisture, activity, mobility, nutrition, and
friction/shear). Lower scores indicate higher risk; for example, a
score of 9 or lower signifies very high risk .
6. A patient with diabetes has a wound on the plantar aspect
of the foot that is small, deep, and "punched out." This is
most characteristic of:
A. Venous ulcer
B. Arterial (ischemic) ulcer
C. Neurotrophic (diabetic) ulcer
D. Pressure injury
Correct Answer: C. Neurotrophic (diabetic) ulcer
Rationale: Diabetic (neurotrophic) ulcers are caused by
peripheral neuropathy (loss of sensation) and poor circulation.
They typically occur on pressure points of the foot (heel, plantar
4
TEST BANK| NSE 211 FINAL EXAM REVIEW WITH
COMPLETE 450 REAL EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS/ ALREADY GRADED A+
(BRAND NEW!!)
1. A nurse assesses a patient who had abdominal surgery 3
days ago. The wound edges are well-approximated, and there
is no drainage. The nurse documents this as healing by which
intention?
A. Secondary intention
B. Tertiary intention
C. Primary intention
D. Delayed primary intention
Correct Answer: C. Primary intention
Rationale: Primary intention healing occurs when a wound is
closed surgically with sutures or staples, bringing the edges
together (approximated). This results in minimal scarring and a
lower risk of infection .
2. Which of the following is the defining characteristic of a
Stage 2 pressure injury?
A. Intact skin with non-blanchable erythema
1
,B. Full-thickness tissue loss with visible bone
C. Partial-thickness loss of dermis presenting as a shallow open
ulcer or intact blister
D. Full-thickness tissue loss covered entirely by eschar
Correct Answer: C. Partial-thickness loss of dermis presenting
as a shallow open ulcer or intact blister
Rationale: A Stage 2 pressure injury is characterized by partial-
thickness loss of skin involving the epidermis and dermis. The
wound bed is viable, pink or red, and moist, and may also
present as an intact or ruptured serum-filled blister. It should not
be used to describe moisture-associated skin damage .
3. A patient has a pressure injury on the heel with a wound
bed that is completely covered by black, hard, necrotic tissue.
The nurse classifies this as:
A. Stage 3
B. Stage 4
C. Deep Tissue Injury
D. Unstageable
Correct Answer: D. Unstageable
Rationale: An unstageable pressure injury is defined by full-
thickness tissue loss where the base of the ulcer is covered by
2
,slough (yellow/tan) or eschar (black/brown), obscuring the true
depth. Stable, dry, intact eschar on the heel should not be
removed .
4. What is the recommended maximum angle of head
elevation to prevent shear forces in a patient at risk for
pressure injuries?
A. 15 degrees
B. 30 degrees
C. 45 degrees
D. 60 degrees
Correct Answer: B. 30 degrees
Rationale: Limiting head elevation to 30 degrees (or using a 30-
degree lateral turn position) helps prevent shear. Shear occurs
when the skin remains stationary while the underlying bone and
deep tissues slide downward, stretching and damaging
capillaries .
5. Which tool is specifically designed to assess a patient's risk
for developing pressure injuries by evaluating sensory
perception, moisture, activity, mobility, nutrition, and
friction/shear?
A. Norton Scale
3
, B. Braden Scale
C. Glasgow Coma Scale
D. Morse Fall Scale
Correct Answer: B. Braden Scale
Rationale: The Braden Scale is the most widely used tool for
predicting pressure injury risk. It includes six subscales (sensory
perception, moisture, activity, mobility, nutrition, and
friction/shear). Lower scores indicate higher risk; for example, a
score of 9 or lower signifies very high risk .
6. A patient with diabetes has a wound on the plantar aspect
of the foot that is small, deep, and "punched out." This is
most characteristic of:
A. Venous ulcer
B. Arterial (ischemic) ulcer
C. Neurotrophic (diabetic) ulcer
D. Pressure injury
Correct Answer: C. Neurotrophic (diabetic) ulcer
Rationale: Diabetic (neurotrophic) ulcers are caused by
peripheral neuropathy (loss of sensation) and poor circulation.
They typically occur on pressure points of the foot (heel, plantar
4
