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    Exam Review

    1. A nurse is assessing a pressure injury with undermining and tunneling. What measurement practice should be followed?
      A)
      Measure undermining and tunneling separately and record them individually.
      B)
      Include undermining and tunneling measurements within the wound's depth.
      C)
      Use a ruler to measure only the wound's length and width.
      D)
      Estimate the measurements visually.
    2. What is the primary advantage of wound healing by primary intention compared to secondary intention?
      A)
      Faster healing with minimal scar formation.
      B)
      Higher risk of infection.
      C)
      Increased granulation tissue formation.
      D)
      Enhanced epidermal migration.
    3. Which factor is most likely to delay healing in a patient with an open wound?
      A)
      Presence of necrotic tissue.
      B)
      Use of sterile dressings.
      C)
      Regular wound irrigation with saline.
      D)
      Excessive moisture in the wound bed.
    4. A nurse is assessing a wound that is in the proliferative phase of healing. Which clinical finding would most likely indicate the presence of granulation tissue?
      A)
      A smooth, pale pink appearance across the wound bed
      B)
      Dry, dark-colored tissue along the wound edges
      C)
      Yellow, stringy substance attached to the wound bed
      D)
      Bright red, moist tissue in the wound bed
    Page 1 of 11

    Exam Review

    1. Which patient is at highest risk for developing a stage 1 pressure ulcer?
      A)
      A patient with adequate hydration and skin care regimen.
      B)
      An immobile patient with poor nutritional status.
      C)
      A mobile patient with a history of diabetes.
      D)
      A patient who regularly changes position every hour.
    2. Which type of wound drainage is most likely indicative of an acute bacterial infection?
      A)
      Purulent drainage
      B)
      Serosanguineous drainage
      C)
      Serous drainage
      D)
      Sanguineous drainage.
    3. A nurse is planning care for a patient with a chronic wound. What is a key component to include in the plan?
      A)
      Pain control prior to dressing changes.
      B)
      Daily use of strong antiseptics.
      C)
      Immediate surgical intervention.
      D)
      Frequent changes of antibiotics.
    4. A patient with darker skin tones is suspected of having a stage 1 pressure ulcer. Which clinical assessment finding would most support this diagnosis?
      A)
      Presence of a blister on the skin.
      B)
      Exposed bone or muscle.
      C)
      A localized area of skin that is warm to the touch.
      D)
      Presence of a deep crater in the skin.
    Page 2 of 11

    Exam Review

    1. When evaluating a patient with a suspected stage 1 pressure ulcer, which intervention is most appropriate to prevent progression?
      A)
      Apply a hydrocolloid dressing.
      B)
      Implement a turning schedule every 2 hours.
      C)
      Debride the area to remove necrotic tissue.
      D)
      Apply antibiotics topically.
    2. What is the primary characteristic of a stage 1 pressure injury?
      A)
      Full-thickness skin loss with visible fat.
      B)
      Partial-thickness skin loss involving the epidermis and dermis.
      C)
      Intact skin with nonblanchable erythema.
      D)
      Deep injury extending down to the bone.
    3. Which debridement method would be most appropriate for a patient with a heavily exudative infected wound?
      A)
      Mechanical debridement
      B)
      Autolytic debridement
      C)
      Surgical debridement
      D)
      Enzymatic debridement
    4. A nurse is documenting a stage 4 pressure injury. Which of the following descriptions accurately fits this stage?
      A)
      Full-thickness tissue loss extending to bone or tendon.
      B)
      Intact skin with nonblanchable erythema.
      C)
      Full-thickness skin loss with visible fat.
      D)
      Partial-thickness skin loss involving the dermis and epidermis.
    Page 3 of 11

    Exam Review

    1. A wound is draining thick, green fluid with a foul odor. What should the nurse suspect?
      A)
      The wound is contaminated with dirt or debris.
      B)
      The wound is healing normally.
      C)
      The wound is showing signs of older bleeding.
      D)
      The wound is infected with Pseudomonas aeruginosa.
    2. Upon inspecting the skin of a bedridden patient, a nurse notes a reddened area over the heel that does not blanch. What is the most appropriate nursing action?
      A)
      Apply a warm compress to the area to improve circulation.
      B)
      Document the finding and recheck in 24 hours.
      C)
      Massage the area gently to promote blood flow.
      D)
      Reposition the patient to relieve pressure on the heel.
    3. A patient presents with a bluish discoloration on the skin following a fall. Which nursing intervention is most appropriate to assess the severity of the contusion?
      A)
      Instruct the patient to avoid using the injured limb.
      B)
      Assess for pain and swelling at the injury site.
      C)
      Administer analgesics without further assessment.
      D)
      Apply a warm compress to the area immediately.
    4. A patient presents with a penetrating eye injury caused by a small metal particle. What is the most immediate nursing intervention?
      A)
      Cover the affected eye with a protective shield and seek immediate ophthalmic consultation.
      B)
      Administer analgesics to manage pain before addressing the eye injury.
      C)
      Apply pressure to the eye to prevent bleeding.
      D)
      Irrigate the eye with sterile saline to remove the foreign object.
    Page 4 of 11

    Exam Review

    1. You are assessing a client with a serum-filled blister on their heel along with partial-thickness skin loss. What is the most appropriate documentation for this condition?
      A)
      Stage 3 pressure injury
      B)
      Unstageable pressure injury
      C)
      Stage 2 pressure injury
      D)
      Stage 1 pressure injury
    2. A nurse is caring for a patient who has just undergone abdominal surgery. The patient suddenly reports feeling a 'pop' at the incision site and you observe that the wound edges have separated with protrusion of abdominal organs. What is the nurse's immediate priority action?
      A)
      Elevate the head of the bed to reduce pressure on the abdominal area.
      B)
      Cover the wound with sterile saline-soaked gauze and notify the surgeon immediately.
      C)
      Reapproximate the wound edges using steri-strips.
      D)
      Apply a dry sterile dressing over the wound.
    3. A client with incontinence is at risk for skin breakdown. What is the most appropriate nursing action to minimize this risk?
      A)
      Use a hot water wash to cleanse the affected area.
      B)
      Cleanse the skin with alcohol-based products.
      C)
      Pat the skin dry and apply a moisture barrier cream.
      D)
      Apply a thick layer of lotion after each incontinence episode.
    4. What is the priority assessment for a patient with an open wound that has a foul-smelling exudate?
      A)
      Check the patient's blood sugar levels.
      B)
      Assess for signs of systemic infection.
      C)
      Measure the wound dimensions.
      D)
      Apply a new dressing over the wound.
    Page 5 of 11

    Exam Review

    1. A patient with a Jackson-Pratt drain post-cholecystectomy reports nausea and the absence of drainage. What should be the nurse's first action?
      A)
      Irrigate the drain with sterile saline.
      B)
      Notify the healthcare provider immediately.
      C)
      Increase the patient's oral fluid intake.
      D)
      Reposition the drain.
    2. Which nursing intervention is crucial for a client with impaired mobility to prevent skin breakdown on bony prominences?
      A)
      Apply talcum powder to areas at risk for breakdown.
      B)
      Encourage the client to drink more fluids.
      C)
      Use pillows and cushions to support and position the client.
      D)
      Perform a complete bed bath daily.
    3. A stage 3 pressure ulcer is noted on a patient's coccyx. What is the primary goal of the nursing care plan for this patient?
      A)
      Ensure complete bed rest.
      B)
      Prevent further tissue breakdown.
      C)
      Encourage high protein diet.
      D)
      Increase patient's fluid intake.
    4. A patient with a stage 3 pressure ulcer on the heel has developed signs of infection. Which of the following actions should the nurse prioritize?
      A)
      Increase the frequency of wound dressing changes.
      B)
      Initiate contact isolation precautions.
      C)
      Apply a non-adherent dressing.
      D)
      Administer prescribed antibiotics.
    Page 6 of 11