FUNDAMENTALS OF NURSING ACTUAL
EXAMINATION SHEET 2026 ACCURATE
ANSWERS GUARANTEED
⫸ 2. The nurse is caring for a patient who was involved in an
automobile accident 2 weeks ago. The patient sustained a head injury
and is unconscious. The nurse is able to identify that the major
element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.. Answer: ANS: A
Pressure is the main element that causes pressure ulcers. Three
pressure-related factors contribute to pressure ulcer development:
pressure intensity, pressure duration, and tissue tolerance. When the
intensity of the pressure exerted on the capillary exceeds 12 to 32 mm
Hg, this occludes the vessel, causing ischemic injury to the tissues it
normally feeds. High pressure over a short time and low pressure over
a long time cause skin breakdown. Resistance (the ability to remain
unaltered by the damaging effect of something), stress (worry or
anxiety), and weight (individuals of all sizes, shapes, and ages acquire
skin breakdown) are not major causes of pressure ulcers.
⫸ 3. Which nursing observation would indicate that the patient was
at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
,b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.. Answer: ANS:
B
The presence and duration of moisture on the skin increase the risk of
ulcer formation by making it susceptible to injury. Moisture can
originate from wound drainage, excessive perspiration, and fecal or
urinary incontinence. Bacteria and enzymes in the stool can enhance
the opportunity for skin breakdown because the skin is moistened and
softened, causing maceration. Eating a balanced diet is important for
nutrition, but eating just two thirds of the meal does not indicate that
the individual is at risk. A raised red rash on the leg again is a concern
and can affect the integrity of the skin, but it is located on the shin,
which is not a high-risk area for skin breakdown. Pressure can
influence capillary refill, leading to skin breakdown, but this capillary
response is within normal limits.
⫸ 4. The wound care nurse visits a patient in the long-term care unit.
The nurse is monitoring a patient with a stage III pressure ulcer. The
wound seems to be healing, and healthy tissue is observed. How
would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer. Answer: ANS: C
When a pressure ulcer has been staged and is beginning to heal, the
ulcer keeps the same stage and is labeled with the words "healing
stage." Once an ulcer has been staged, the stage endures even as the
ulcer heals. This ulcer was labeled a stage III, it cannot return to a
,previous stage such as stage I or II. This ulcer is healing, so it is no
longer labeled a stage III.
⫸ 5. The nurse is admitting an older patient from a nursing home.
During the assessment, the nurse notes a shallow open ulcer without
slough on the right heel of the patient. This pressure ulcer would be
staged as stage
a. I.
b. II.
c. III.
d. IV.. Answer: ANS: B
This would be a stage II pressure ulcer because it presents as partial-
thickness skin loss involving epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an abrasion, blister, or shallow
crater. Stage I is intact skin with nonblanchable redness over a bony
prominence. With a Stage III pressure ulcer, subcutaneous fat may be
visible, but bone, tendon, and muscles are not exposed. Stage IV
involves full-thickness tissue loss with exposed bone, tendon, or
muscle.
⫸ 6. The nurse is completing a skin assessment on a patient with
darkly pigmented skin. Which of the following would be used first to
assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light. Answer: ANS: D
, When assessing a patient with darkly pigmented skin, proper lighting
is essential to accurately complete the first step in assessment—
inspection—and the whole assessment process. Natural light or a
halogen light is recommended. Fluorescent light sources can produce
blue tones on darkly pigmented skin and can interfere with an
accurate assessment. Other items that could possibly be used during
the assessment include gloves for infection control, a disposable
measuring device to measure the size of the wound, and a cotton-
tipped applicator to measure the depth of the wound, but these items
not the first item used.
⫸ 7. The nurse is caring for a patient with a stage IV pressure ulcer.
The nurse recalls that a pressure ulcer takes time to heal and is an
example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.. Answer: ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis
and heal by scar formation because the deeper structures do not
regenerate, hence the need for full-thickness repair. The full-thickness
repair has three phases: inflammatory, proliferative, and remodeling.
A wound heals by primary intention when wounds such as surgical
wounds have little tissue loss; the skin edges are approximated or
closed, and the risk for infection is low. Partial-thickness repairs are
done on partial-thickness wounds that are shallow, involving loss of
the epidermis and maybe partial loss of the dermis. These wounds
heal by regeneration because the epidermis regenerates. Tertiary
intention is seen when a wound is left open for several days, and then
EXAMINATION SHEET 2026 ACCURATE
ANSWERS GUARANTEED
⫸ 2. The nurse is caring for a patient who was involved in an
automobile accident 2 weeks ago. The patient sustained a head injury
and is unconscious. The nurse is able to identify that the major
element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.. Answer: ANS: A
Pressure is the main element that causes pressure ulcers. Three
pressure-related factors contribute to pressure ulcer development:
pressure intensity, pressure duration, and tissue tolerance. When the
intensity of the pressure exerted on the capillary exceeds 12 to 32 mm
Hg, this occludes the vessel, causing ischemic injury to the tissues it
normally feeds. High pressure over a short time and low pressure over
a long time cause skin breakdown. Resistance (the ability to remain
unaltered by the damaging effect of something), stress (worry or
anxiety), and weight (individuals of all sizes, shapes, and ages acquire
skin breakdown) are not major causes of pressure ulcers.
⫸ 3. Which nursing observation would indicate that the patient was
at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
,b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.. Answer: ANS:
B
The presence and duration of moisture on the skin increase the risk of
ulcer formation by making it susceptible to injury. Moisture can
originate from wound drainage, excessive perspiration, and fecal or
urinary incontinence. Bacteria and enzymes in the stool can enhance
the opportunity for skin breakdown because the skin is moistened and
softened, causing maceration. Eating a balanced diet is important for
nutrition, but eating just two thirds of the meal does not indicate that
the individual is at risk. A raised red rash on the leg again is a concern
and can affect the integrity of the skin, but it is located on the shin,
which is not a high-risk area for skin breakdown. Pressure can
influence capillary refill, leading to skin breakdown, but this capillary
response is within normal limits.
⫸ 4. The wound care nurse visits a patient in the long-term care unit.
The nurse is monitoring a patient with a stage III pressure ulcer. The
wound seems to be healing, and healthy tissue is observed. How
would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer. Answer: ANS: C
When a pressure ulcer has been staged and is beginning to heal, the
ulcer keeps the same stage and is labeled with the words "healing
stage." Once an ulcer has been staged, the stage endures even as the
ulcer heals. This ulcer was labeled a stage III, it cannot return to a
,previous stage such as stage I or II. This ulcer is healing, so it is no
longer labeled a stage III.
⫸ 5. The nurse is admitting an older patient from a nursing home.
During the assessment, the nurse notes a shallow open ulcer without
slough on the right heel of the patient. This pressure ulcer would be
staged as stage
a. I.
b. II.
c. III.
d. IV.. Answer: ANS: B
This would be a stage II pressure ulcer because it presents as partial-
thickness skin loss involving epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an abrasion, blister, or shallow
crater. Stage I is intact skin with nonblanchable redness over a bony
prominence. With a Stage III pressure ulcer, subcutaneous fat may be
visible, but bone, tendon, and muscles are not exposed. Stage IV
involves full-thickness tissue loss with exposed bone, tendon, or
muscle.
⫸ 6. The nurse is completing a skin assessment on a patient with
darkly pigmented skin. Which of the following would be used first to
assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light. Answer: ANS: D
, When assessing a patient with darkly pigmented skin, proper lighting
is essential to accurately complete the first step in assessment—
inspection—and the whole assessment process. Natural light or a
halogen light is recommended. Fluorescent light sources can produce
blue tones on darkly pigmented skin and can interfere with an
accurate assessment. Other items that could possibly be used during
the assessment include gloves for infection control, a disposable
measuring device to measure the size of the wound, and a cotton-
tipped applicator to measure the depth of the wound, but these items
not the first item used.
⫸ 7. The nurse is caring for a patient with a stage IV pressure ulcer.
The nurse recalls that a pressure ulcer takes time to heal and is an
example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.. Answer: ANS: C
Pressure ulcers are full-thickness wounds that extend into the dermis
and heal by scar formation because the deeper structures do not
regenerate, hence the need for full-thickness repair. The full-thickness
repair has three phases: inflammatory, proliferative, and remodeling.
A wound heals by primary intention when wounds such as surgical
wounds have little tissue loss; the skin edges are approximated or
closed, and the risk for infection is low. Partial-thickness repairs are
done on partial-thickness wounds that are shallow, involving loss of
the epidermis and maybe partial loss of the dermis. These wounds
heal by regeneration because the epidermis regenerates. Tertiary
intention is seen when a wound is left open for several days, and then
