NSG 300 EXAM 2 QUESTIONS AND
ANSWERS 100% PASS 2026 EDITION
What are 3 pressure related factors that contribute to pressure ulcer development? - ANS 1.
Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - ANS If pressure applied over a capillary exceeds
normal capillary pressure and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - ANS tissue death
Does blanching occur in dark skinned patients? - ANS No, blanching does not occur but color,
texture and temp may differ from surrounding area
What does pressure duration assess? - ANS Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - ANS the ability of tissue to endure pressure which is dependent
on the integrity of the tissue and supporting structures
What are risk factors of pressure injuries? - ANS ◦Impaired sensory perception
1
@2026 EDITION ALLRIGHTS RESERVED
,◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - ANS Wound location,
staging, type and approximate percentage of tissue in wound bed, wound dimensions (sinus
tracts and tunneling), exudate description and condition of surrounding skin
stage 1 pressure injury - ANS Intact skin with nonblanchable redness
stage 2 pressure injury - ANS partial thickness skin loss involving epidermis, dermis or both
and, shallow abrasion or open blister looking
stage 3 pressure injury - ANS full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury - ANS full thickness with exposed bone, muscle or tendon and may
have eschar
What characteristics does stage 3 and 4 pressure injuries share? - ANS They may have slough,
undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should the student nurse
expect to see? - ANS A yellow or white, stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the student nurse
expect to see? - ANS brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - ANS Tissue loss but depth unknown because
wound bed is obscured by slough and/or eschar
2
@2026 EDITION ALLRIGHTS RESERVED
, A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its
own". What education should the nurse provide? - ANS Slough and eschar must be removed
by a clinician to determine the stage and in order for healing to occur
suspected deep tissue injury - ANS Purple or maroon localized area of discolored intact skin
or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Depth unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What should the
student nurse expect to see? - ANS Red, moist tissue which indicates progression toward
healing
What should the nurse document when assessing exudate? - ANS Amount, color, consistency
and odor
The student nurse sees an excess amount of exudate in the wound bed. What does this
indicate? - ANS The presence of infection
What should the nurse look for when assessing the periwound area? Why is it important? -
ANS Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - ANS Allows a nurse to understand the risks
associated with a wound and implications for healing
How does a partial thickness wound heal? - ANS Heals by regeneration
How does a full thickness would heal? - ANS Heals by forming new tissue which takes longer
3
@2026 EDITION ALLRIGHTS RESERVED
ANSWERS 100% PASS 2026 EDITION
What are 3 pressure related factors that contribute to pressure ulcer development? - ANS 1.
Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - ANS If pressure applied over a capillary exceeds
normal capillary pressure and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - ANS tissue death
Does blanching occur in dark skinned patients? - ANS No, blanching does not occur but color,
texture and temp may differ from surrounding area
What does pressure duration assess? - ANS Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - ANS the ability of tissue to endure pressure which is dependent
on the integrity of the tissue and supporting structures
What are risk factors of pressure injuries? - ANS ◦Impaired sensory perception
1
@2026 EDITION ALLRIGHTS RESERVED
,◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - ANS Wound location,
staging, type and approximate percentage of tissue in wound bed, wound dimensions (sinus
tracts and tunneling), exudate description and condition of surrounding skin
stage 1 pressure injury - ANS Intact skin with nonblanchable redness
stage 2 pressure injury - ANS partial thickness skin loss involving epidermis, dermis or both
and, shallow abrasion or open blister looking
stage 3 pressure injury - ANS full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury - ANS full thickness with exposed bone, muscle or tendon and may
have eschar
What characteristics does stage 3 and 4 pressure injuries share? - ANS They may have slough,
undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should the student nurse
expect to see? - ANS A yellow or white, stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the student nurse
expect to see? - ANS brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - ANS Tissue loss but depth unknown because
wound bed is obscured by slough and/or eschar
2
@2026 EDITION ALLRIGHTS RESERVED
, A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its
own". What education should the nurse provide? - ANS Slough and eschar must be removed
by a clinician to determine the stage and in order for healing to occur
suspected deep tissue injury - ANS Purple or maroon localized area of discolored intact skin
or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Depth unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What should the
student nurse expect to see? - ANS Red, moist tissue which indicates progression toward
healing
What should the nurse document when assessing exudate? - ANS Amount, color, consistency
and odor
The student nurse sees an excess amount of exudate in the wound bed. What does this
indicate? - ANS The presence of infection
What should the nurse look for when assessing the periwound area? Why is it important? -
ANS Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - ANS Allows a nurse to understand the risks
associated with a wound and implications for healing
How does a partial thickness wound heal? - ANS Heals by regeneration
How does a full thickness would heal? - ANS Heals by forming new tissue which takes longer
3
@2026 EDITION ALLRIGHTS RESERVED
