Integumentary System 2026 Wound Care Standards

1. A nurse is assessing a pressure injury. Which finding indicates a Stage 1 pressure injury? A. Full-thickness tissue loss with exposed bone B. Non-blanchable erythema of intact skin C. Visible subcutaneous fat D. Deep crater with tunneling Correct Answer: B. Non-blanchable erythema of intact skin Rationale: Stage 1 pressure injuries present as intact skin with persistent redness that does not blanch. 2. Which intervention is most effective for preventing pressure injuries in immobile patients? A. Massage bony prominences B. Reposition at least every 2 hours C. Keep patient in one position for stability D. Restrict fluid intake Correct Answer: B. Reposition at least every 2 hours Rationale: Frequent repositioning reduces prolonged pressure and tissue ischemia. 3. Which wound characteristic suggests infection? A. Pale pink tissue B. Purulent drainage and odor C. Dry intact skin D. Decreasing wound size Correct Answer: B. Purulent drainage and odor Rationale: Purulent drainage and foul odor are classic signs of infection. 4. Which dressing is most appropriate for a heavily exudating wound? A. Dry gauze only B. Hydrocolloid dressing C. Absorptive foam dressing D. Transparent film only Correct Answer: C. Absorptive foam dressing Rationale: Foam dressings manage high exudate by absorbing excess fluid. 5. Which finding is consistent with a Stage 3 pressure injury? A. Intact skin with redness B. Partial-thickness skin loss C. Full-thickness skin loss with visible fat D. Exposed bone and tendon only Correct Answer: C. Full-thickness skin loss with visible fat Rationale: Stage 3 involves full-thickness skin loss without exposed bone. 6. Which factor increases risk for pressure injury development? A. Good hydration B. Immobility C. Regular ambulation D. High protein intake Correct Answer: B. Immobility Rationale: Immobility leads to prolonged pressure over bony areas. 7. Which dressing promotes moist wound healing for shallow wounds? A. Dry sterile gauze B. Hydrocolloid dressing C. Open air exposure D. No dressing Correct Answer: B. Hydrocolloid dressing Rationale: Hydrocolloids maintain a moist environment for healing. 8. Which sign indicates wound dehiscence? A. Pink granulation tissue B. Separation of wound edges C. Decreasing drainage D. Scar formation Correct Answer: B. Separation of wound edges Rationale: Dehiscence is partial or complete separation of a surgical incision. 9. Which patient is at highest risk for impaired skin integrity? A. Ambulatory patient B. Bedridden elderly patient C. Athlete D. Healthy young adult Correct Answer: B. Bedridden elderly patient Rationale: Elderly immobility increases risk for skin breakdown. 10. Which nutritional component is essential for wound healing? A. Protein B. Sugar C. Alcohol D. Caffeine Correct Answer: A. Protein Rationale: Protein is required for tissue repair and collagen formation. 11. Which wound stage includes exposed bone, tendon, or muscle? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 Correct Answer: D. Stage 4 Rationale: Stage 4 involves full-thickness tissue loss with exposed structures. 12. Which intervention helps reduce shear force? A. Dragging patient in bed B. Using draw sheets to lift patient C. Keeping bed flat D. Encouraging sliding down in bed Correct Answer: B. Using draw sheets to lift patient Rationale: Proper lifting reduces friction and shear injury. 13. Which solution is commonly used for wound irrigation? A. Sterile normal saline B. Alcohol C. Hydrogen peroxide routinely D. Vinegar Correct Answer: A. Sterile normal saline Rationale: Normal saline is safe for wound cleansing.