FUNDAMENTALS OF NURSING CHAPTER 48:
SKIN INTEGRITY AND WOUND CARE
PRACTICE QUESTIONS AND ANSWERS
GRADED A+ 2026
1. 1. The nurse is working on a medical-surgical unit that has been participating in a
research project associated with pressure ulcers. The nurse recognizes that the risk factors
that predispose a patient to pressure ulcer development
include
a. A diet low in calories and fat.
,b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.: ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness
are unable to protect themselves. The patient may feel the pressure but may not
understand what to do to relieve the discomfort or to communicate that he or she is
feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and
moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet
low in calories and fat are not included among the predisposing factors.
2. 2. The nurse is caring for a patient who was involved in an automobile acci- dent 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.: 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 ettect 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. 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.: 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 attect 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. 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: ANS: C
SKIN INTEGRITY AND WOUND CARE
PRACTICE QUESTIONS AND ANSWERS
GRADED A+ 2026
1. 1. The nurse is working on a medical-surgical unit that has been participating in a
research project associated with pressure ulcers. The nurse recognizes that the risk factors
that predispose a patient to pressure ulcer development
include
a. A diet low in calories and fat.
,b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.: ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness
are unable to protect themselves. The patient may feel the pressure but may not
understand what to do to relieve the discomfort or to communicate that he or she is
feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and
moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet
low in calories and fat are not included among the predisposing factors.
2. 2. The nurse is caring for a patient who was involved in an automobile acci- dent 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.: 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 ettect 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. 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.: 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 attect 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. 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: ANS: C
