NUR 216 LATEST 2026 STUDY GUIDE QUESTIONS AND
ANSWERS MARKED A+
✔✔ABCDEs of melanoma - ✔✔A= asymmetry
B= border (irregular)
C= varies (brown, balck, tan)
D= diameter (usually >6mm)
E= evolving (looks different?)
✔✔flat lesions: macule - ✔✔freckles, mole, measles, scarlet fever
✔✔flat lesions: patch - ✔✔birthmark, vitiligo, hormonal changes
✔✔raised lesions: papule - ✔✔wart, elevated mole, skin tags
✔✔raised lesions: plaque - ✔✔psoriasis, eczema
✔✔raised solid lesions: - ✔✔tumor (neoplasm)
wheal (inspect bites, allergic reaction, hives
nodule(melanoma)
✔✔raised, fluid lesions (vesicles) - ✔✔pustule (acne, cold sore)
cyst: cystic acne, sebaceous cyst
bulla: blister, medication reaction
✔✔secondary lesions - ✔✔revolve from primary lesions and with time the
characteristics change:
-crust, scaling, ulcers
✔✔pressure injuries/ulcers risk factors - ✔✔risk factors:
-elderly: thinning skin and less SQ fat
-excessive moisture (urinary issues or fecal)
-shearing and friction
-immobility
-obesity
-poor nutrition and hydration
-vascular disease (lack of circulation)
-sensory deficits
-edema
-chronic disease(DM, liver failure
✔✔pressure points for injuries - ✔✔Supine:
back of head
shoulder
elbow
,butt
heel
Side laying (lateral):
ear
shoulder
elbow
hip
thigh
leg
heel
prone:
elbow
ribcage
thigh
knees
toes
✔✔pressure injury: color of wound bed - ✔✔red: healthy regeneration
yellow: infection, purulent drainage or slough
black: eschar or necrotic tissue - requires removal for healing
✔✔pressure injury: size of wound - ✔✔length, width, depth, undermining, tunneling
✔✔pressure injury: exudate/drainage - ✔✔COCA
✔✔pressure injury: surrounding skin - ✔✔intact, macerated, edematous, erythematous
✔✔serosanguineous drainage - ✔✔mixture of serum and red blood cells
✔✔Sanguineous drainage - ✔✔bloody drainage
✔✔serous drainage - ✔✔clear, watery plasma
✔✔purulent drainage - ✔✔thick green, yellow, or brown drainage
✔✔stage 1 pressure ulcer - ✔✔reddened area that does NOT blanch
skin is intact
texture different (firmer or softer) than surrounding tissue
darker skin tones: blue or purple hue
NEVER rub a reddened area
✔✔stage 2 pressure ulcer - ✔✔partial thickness loss of skin
skin breakdown of the epidermis and dermis
red/pink, shiny wound bed
, ✔✔stage 3 pressure ulcer: - ✔✔-full thickness skin loss
drainage or necrosis tissue, subcutaneous fat may be visible
-dead tissue may be present in wound bed
-deep without exposed muscle or bone
✔✔stage 4 pressure ulcer - ✔✔-Full-thickness skin and tissue loss with exposed bone,
muscle, or tendon
-tissue necrosis or damage to muscle, bone or underlying structures
-slough, eschar, tunneling, undermining
(osteomyelitis bone infection)
✔✔unstageable - ✔✔ulcer is covered with slough or eschar
depth unknown
✔✔deep tissue injury DTI - ✔✔discoloration but skin is INTACT
damage to underlying tissue
appears as a bruise with intact skin
deeper discoloration
✔✔Pressure injury management pearls - ✔✔S: surface should be smooth
K: keep moving
I: incontinence management
N: nutrition (protein)
✔✔pressure injury nursing interventions: - ✔✔-lift device
-specialty mattress
-assess every 8 hours or per shift: braden scale
-clean skin with warm water and little friction
-moisture barrier cream
-nutrient dense foods: high protein diet
-provide wound care per facility guidelines
-prevention is key!!
-inspect everyday
-ensure linens are clean and wrinkle free
-reposition q2hrs or more, shift weight q15mins (chair)
-limit chair time to 1 hour
- keeping head less than 30 degrees
-float heels
-ambulate - ROM
✔✔hair care - ✔✔color and texture
- due to melanin productions
-thick to fine
-distribution (TANNER staging, pubic region)
-evenly distributed
ANSWERS MARKED A+
✔✔ABCDEs of melanoma - ✔✔A= asymmetry
B= border (irregular)
C= varies (brown, balck, tan)
D= diameter (usually >6mm)
E= evolving (looks different?)
✔✔flat lesions: macule - ✔✔freckles, mole, measles, scarlet fever
✔✔flat lesions: patch - ✔✔birthmark, vitiligo, hormonal changes
✔✔raised lesions: papule - ✔✔wart, elevated mole, skin tags
✔✔raised lesions: plaque - ✔✔psoriasis, eczema
✔✔raised solid lesions: - ✔✔tumor (neoplasm)
wheal (inspect bites, allergic reaction, hives
nodule(melanoma)
✔✔raised, fluid lesions (vesicles) - ✔✔pustule (acne, cold sore)
cyst: cystic acne, sebaceous cyst
bulla: blister, medication reaction
✔✔secondary lesions - ✔✔revolve from primary lesions and with time the
characteristics change:
-crust, scaling, ulcers
✔✔pressure injuries/ulcers risk factors - ✔✔risk factors:
-elderly: thinning skin and less SQ fat
-excessive moisture (urinary issues or fecal)
-shearing and friction
-immobility
-obesity
-poor nutrition and hydration
-vascular disease (lack of circulation)
-sensory deficits
-edema
-chronic disease(DM, liver failure
✔✔pressure points for injuries - ✔✔Supine:
back of head
shoulder
elbow
,butt
heel
Side laying (lateral):
ear
shoulder
elbow
hip
thigh
leg
heel
prone:
elbow
ribcage
thigh
knees
toes
✔✔pressure injury: color of wound bed - ✔✔red: healthy regeneration
yellow: infection, purulent drainage or slough
black: eschar or necrotic tissue - requires removal for healing
✔✔pressure injury: size of wound - ✔✔length, width, depth, undermining, tunneling
✔✔pressure injury: exudate/drainage - ✔✔COCA
✔✔pressure injury: surrounding skin - ✔✔intact, macerated, edematous, erythematous
✔✔serosanguineous drainage - ✔✔mixture of serum and red blood cells
✔✔Sanguineous drainage - ✔✔bloody drainage
✔✔serous drainage - ✔✔clear, watery plasma
✔✔purulent drainage - ✔✔thick green, yellow, or brown drainage
✔✔stage 1 pressure ulcer - ✔✔reddened area that does NOT blanch
skin is intact
texture different (firmer or softer) than surrounding tissue
darker skin tones: blue or purple hue
NEVER rub a reddened area
✔✔stage 2 pressure ulcer - ✔✔partial thickness loss of skin
skin breakdown of the epidermis and dermis
red/pink, shiny wound bed
, ✔✔stage 3 pressure ulcer: - ✔✔-full thickness skin loss
drainage or necrosis tissue, subcutaneous fat may be visible
-dead tissue may be present in wound bed
-deep without exposed muscle or bone
✔✔stage 4 pressure ulcer - ✔✔-Full-thickness skin and tissue loss with exposed bone,
muscle, or tendon
-tissue necrosis or damage to muscle, bone or underlying structures
-slough, eschar, tunneling, undermining
(osteomyelitis bone infection)
✔✔unstageable - ✔✔ulcer is covered with slough or eschar
depth unknown
✔✔deep tissue injury DTI - ✔✔discoloration but skin is INTACT
damage to underlying tissue
appears as a bruise with intact skin
deeper discoloration
✔✔Pressure injury management pearls - ✔✔S: surface should be smooth
K: keep moving
I: incontinence management
N: nutrition (protein)
✔✔pressure injury nursing interventions: - ✔✔-lift device
-specialty mattress
-assess every 8 hours or per shift: braden scale
-clean skin with warm water and little friction
-moisture barrier cream
-nutrient dense foods: high protein diet
-provide wound care per facility guidelines
-prevention is key!!
-inspect everyday
-ensure linens are clean and wrinkle free
-reposition q2hrs or more, shift weight q15mins (chair)
-limit chair time to 1 hour
- keeping head less than 30 degrees
-float heels
-ambulate - ROM
✔✔hair care - ✔✔color and texture
- due to melanin productions
-thick to fine
-distribution (TANNER staging, pubic region)
-evenly distributed
