NUR 2356 FINAL EXAM 2026/2027 | Multidimensional Care I
MDC 1 Modules 8-10 Review | Verified Q&A | Rasmussen |
Pass Guaranteed - A+ Graded
SECTION 1: WOUND HEALING & SKIN INTEGRITY (25 Questions)
Q1: A 68-year-old client underwent an appendectomy 3 days ago. The nurse observes
the surgical incision edges are well-approximated with minimal drainage. Which phase
of wound healing is this client most likely experiencing?
A. Maturation phase
B. Proliferative phase
C. Inflammatory phase
D. Hemostasis phase
Correct Answer: B
Rationale: The proliferative phase occurs from days 5-21 and is characterized by wound
contraction, granulation tissue formation, and epithelialization. Since the incision is 3
days old, the client is transitioning from inflammatory to proliferative phase. The
inflammatory phase (days 1-5) involves vasodilation and exudate production.
Maturation (day 21+) involves collagen remodeling. Hemostasis occurs immediately
after injury. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Wound Healing Phases.
Q2: A nurse is caring for a client with a Stage II pressure injury on the sacrum. Which
finding would the nurse expect to document?
A. Non-blanchable erythema of intact skin
B. Full-thickness tissue loss with visible fascia
C. Partial-thickness skin loss with exposed dermis
D. Unstageable wound covered with slough
Correct Answer: C
,Rationale: Stage II pressure injuries present as partial-thickness skin loss with exposed
dermis; the wound bed is viable, pink or red, moist, and may present as an intact or
ruptured serum-filled blister. Non-blanchable erythema describes Stage I. Full-thickness
with fascia exposure describes Stage III. Unstageable wounds are covered with slough
or eschar, preventing staging. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Pressure
Injury Staging.
Q3: The nurse is developing a care plan for a client at high risk for pressure injury
development. Which intervention is the highest priority to prevent skin breakdown?
A. Apply moisture barrier cream after each incontinence episode
B. Reposition the client every 2 hours while in bed
C. Elevate the head of bed to 45 degrees at all times
D. Massage bony prominences with lotion three times daily
Correct Answer: B
Rationale: Repositioning every 2 hours is the highest priority intervention to relieve
pressure on bony prominences and maintain tissue perfusion. While moisture barrier
cream is important for incontinent clients, pressure relief takes priority. HOB should be
maintained at ≤30° to prevent shear forces. Massaging bony prominences is
contraindicated as it can cause deep tissue trauma. VERIFIED ✓ — Rasmussen
NUR2356 Module 8: Pressure Injury Prevention.
Q4: A client returns from surgery with a surgical incision closed with sutures. The nurse
recognizes this wound will heal by which mechanism?
A. Secondary intention
B. Tertiary intention
C. Primary intention
D. Fourth intention
Correct Answer: C
,Rationale: Primary intention healing occurs when wound edges are surgically
approximated with minimal tissue loss, such as with sutures or staples, resulting in
minimal scarring. Secondary intention involves extensive tissue loss where the wound is
left open to heal from the bottom up. Tertiary intention (delayed primary closure) occurs
when a wound is intentionally left open due to infection or contamination and closed
later. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Wound Healing Types.
Q5: During wound assessment, the nurse notes drainage that is pale red and watery.
How should the nurse document this exudate?
A. Sanguineous
B. Serosanguineous
C. Serous
D. Purulent
Correct Answer: B
Rationale: Serosanguineous drainage is pale red, watery, and composed of both serum
and blood. Sanguineous drainage is bright red and indicates fresh bleeding. Serous
drainage is clear, thin, and watery. Purulent drainage is thick, opaque, yellow, green, or
tan and indicates infection. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Wound
Assessment.
Q6: A nurse is caring for a client with a full-thickness wound healing by secondary
intention. During the inflammatory phase, which assessment finding would be
expected?
A. Collagen deposition and wound contraction
B. Granulation tissue formation
C. Redness, warmth, and mild edema at the wound edges
D. Scar tissue maturation and strengthening
Correct Answer: C
Rationale: The inflammatory phase (days 1-5) is characterized by vasodilation,
increased vascular permeability, and migration of white blood cells to the wound,
, resulting in redness, warmth, edema, and pain at the wound edges. Collagen deposition
and wound contraction occur during the proliferative phase. Granulation tissue forms
during the proliferative phase. Scar maturation occurs during the maturation phase (day
21+). VERIFIED ✓ — Rasmussen NUR2356 Module 8: Inflammatory Phase.
Q7: The nurse is using the Braden Scale to assess a client's risk for pressure injury
development. Which component is NOT included in the Braden Scale?
A. Mobility
B. Nutrition
C. Friction and shear
D. Body mass index
Correct Answer: D
Rationale: The Braden Scale assesses six components: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. Body mass index is not a component of
the Braden Scale. A score of ≤18 indicates high risk for pressure injury development.
VERIFIED ✓ — Rasmussen NUR2356 Module 8: Risk Assessment Tools.
Q8: A client with a Stage IV pressure injury on the heel has wound drainage that is thick,
yellow, and has a foul odor. Which type of exudate is the nurse observing?
A. Sanguineous
B. Serous
C. Serosanguineous
D. Purulent
Correct Answer: D
Rationale: Purulent exudate is thick, opaque, and may be yellow, green, or tan with a foul
or musty odor, indicating infection and the presence of bacteria, white blood cells, and
cellular debris. Sanguineous drainage is bright red (fresh bleeding). Serous is clear and
watery. Serosanguineous is pale red and watery. VERIFIED ✓ — Rasmussen NUR2356
Module 8: Wound Exudate Types.
MDC 1 Modules 8-10 Review | Verified Q&A | Rasmussen |
Pass Guaranteed - A+ Graded
SECTION 1: WOUND HEALING & SKIN INTEGRITY (25 Questions)
Q1: A 68-year-old client underwent an appendectomy 3 days ago. The nurse observes
the surgical incision edges are well-approximated with minimal drainage. Which phase
of wound healing is this client most likely experiencing?
A. Maturation phase
B. Proliferative phase
C. Inflammatory phase
D. Hemostasis phase
Correct Answer: B
Rationale: The proliferative phase occurs from days 5-21 and is characterized by wound
contraction, granulation tissue formation, and epithelialization. Since the incision is 3
days old, the client is transitioning from inflammatory to proliferative phase. The
inflammatory phase (days 1-5) involves vasodilation and exudate production.
Maturation (day 21+) involves collagen remodeling. Hemostasis occurs immediately
after injury. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Wound Healing Phases.
Q2: A nurse is caring for a client with a Stage II pressure injury on the sacrum. Which
finding would the nurse expect to document?
A. Non-blanchable erythema of intact skin
B. Full-thickness tissue loss with visible fascia
C. Partial-thickness skin loss with exposed dermis
D. Unstageable wound covered with slough
Correct Answer: C
,Rationale: Stage II pressure injuries present as partial-thickness skin loss with exposed
dermis; the wound bed is viable, pink or red, moist, and may present as an intact or
ruptured serum-filled blister. Non-blanchable erythema describes Stage I. Full-thickness
with fascia exposure describes Stage III. Unstageable wounds are covered with slough
or eschar, preventing staging. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Pressure
Injury Staging.
Q3: The nurse is developing a care plan for a client at high risk for pressure injury
development. Which intervention is the highest priority to prevent skin breakdown?
A. Apply moisture barrier cream after each incontinence episode
B. Reposition the client every 2 hours while in bed
C. Elevate the head of bed to 45 degrees at all times
D. Massage bony prominences with lotion three times daily
Correct Answer: B
Rationale: Repositioning every 2 hours is the highest priority intervention to relieve
pressure on bony prominences and maintain tissue perfusion. While moisture barrier
cream is important for incontinent clients, pressure relief takes priority. HOB should be
maintained at ≤30° to prevent shear forces. Massaging bony prominences is
contraindicated as it can cause deep tissue trauma. VERIFIED ✓ — Rasmussen
NUR2356 Module 8: Pressure Injury Prevention.
Q4: A client returns from surgery with a surgical incision closed with sutures. The nurse
recognizes this wound will heal by which mechanism?
A. Secondary intention
B. Tertiary intention
C. Primary intention
D. Fourth intention
Correct Answer: C
,Rationale: Primary intention healing occurs when wound edges are surgically
approximated with minimal tissue loss, such as with sutures or staples, resulting in
minimal scarring. Secondary intention involves extensive tissue loss where the wound is
left open to heal from the bottom up. Tertiary intention (delayed primary closure) occurs
when a wound is intentionally left open due to infection or contamination and closed
later. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Wound Healing Types.
Q5: During wound assessment, the nurse notes drainage that is pale red and watery.
How should the nurse document this exudate?
A. Sanguineous
B. Serosanguineous
C. Serous
D. Purulent
Correct Answer: B
Rationale: Serosanguineous drainage is pale red, watery, and composed of both serum
and blood. Sanguineous drainage is bright red and indicates fresh bleeding. Serous
drainage is clear, thin, and watery. Purulent drainage is thick, opaque, yellow, green, or
tan and indicates infection. VERIFIED ✓ — Rasmussen NUR2356 Module 8: Wound
Assessment.
Q6: A nurse is caring for a client with a full-thickness wound healing by secondary
intention. During the inflammatory phase, which assessment finding would be
expected?
A. Collagen deposition and wound contraction
B. Granulation tissue formation
C. Redness, warmth, and mild edema at the wound edges
D. Scar tissue maturation and strengthening
Correct Answer: C
Rationale: The inflammatory phase (days 1-5) is characterized by vasodilation,
increased vascular permeability, and migration of white blood cells to the wound,
, resulting in redness, warmth, edema, and pain at the wound edges. Collagen deposition
and wound contraction occur during the proliferative phase. Granulation tissue forms
during the proliferative phase. Scar maturation occurs during the maturation phase (day
21+). VERIFIED ✓ — Rasmussen NUR2356 Module 8: Inflammatory Phase.
Q7: The nurse is using the Braden Scale to assess a client's risk for pressure injury
development. Which component is NOT included in the Braden Scale?
A. Mobility
B. Nutrition
C. Friction and shear
D. Body mass index
Correct Answer: D
Rationale: The Braden Scale assesses six components: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. Body mass index is not a component of
the Braden Scale. A score of ≤18 indicates high risk for pressure injury development.
VERIFIED ✓ — Rasmussen NUR2356 Module 8: Risk Assessment Tools.
Q8: A client with a Stage IV pressure injury on the heel has wound drainage that is thick,
yellow, and has a foul odor. Which type of exudate is the nurse observing?
A. Sanguineous
B. Serous
C. Serosanguineous
D. Purulent
Correct Answer: D
Rationale: Purulent exudate is thick, opaque, and may be yellow, green, or tan with a foul
or musty odor, indicating infection and the presence of bacteria, white blood cells, and
cellular debris. Sanguineous drainage is bright red (fresh bleeding). Serous is clear and
watery. Serosanguineous is pale red and watery. VERIFIED ✓ — Rasmussen NUR2356
Module 8: Wound Exudate Types.
