NURSING NOW CATALANO
COMPREHENSIVE SOLUTION 2026
QUESTIONS WITH SOLUTIONS GRADED A+
⩥ 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
COMPREHENSIVE SOLUTION 2026
QUESTIONS WITH SOLUTIONS GRADED A+
⩥ 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
