NUR 242 Med/Surg Exam 1 Certification Exam Questions and Correct
Answers (Verified Answers) Plus Rationales 2026 Q&A | Instant
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Stage 1 pressure ulcer -ANSWERS-- skin is intact
- area, usually over a bony prominence, red and does not blanch with
external pressure
Stage 2 pressure ulcer -ANSWERS-- skin is not intact
- there partial -thickness skin loss of the epidermis or dermis
- ulcer is superficial and maybe an abrasion, a blister (open or fluid-
filled, or a shallow crater)
Stage 3 pressure ulcer -ANSWERS-- skin loss is full thickness
subcutaneous tissue may be damaged or necrotic
- damage extends to fascia, bone, tendon and muscle
- undermining and tunneling may or may not be present
Stage 4 pressure ulcer -ANSWERS--Skin loss is full thickness with
exposed or palpable muscle, tendon, or bone
- often excludes undermining and tunneling
- sinus tracts may develop
- slough and eschar are often present or at least part of the wound
,Unstageable -ANSWERS-- skin loss is full thickness and the base is
completely covered with slough, or eschar, obscurring the true depth of
the wound
Wet to damp saline moistened gauze -ANSWERS-necrotic debris is
mechanically removed but with less trauma to healing tissue
Continuous wet gauze -ANSWERS-wound surface continually bathed
with wetting agent of choice, promoting dilution of viscous exudate and
softening of dry eschar
Topical enzyme preparations -ANSWERS-proteolytic action of thick,
adherent eschar causes breakdown of denatured protein and more
rapid separation of necrotic tissue
Moisture - retentive dressing -ANSWERS-Spontaneous separation of
necrotic tissue is promoted by autolysis
Wound - vac - negative pressure wound therapy -ANSWERS-can reduce
and or close chronic injuries by removing fluids or infectious materials,
enhancing granulation. Should be changed every 48 to 72 hours.
Hyperbaric - oxygen therapy (HBOT) -ANSWERS-administration of
oxygen under high pressure, raising tissue oxygen concentration.
, Usually received under limb life-threatening wounds such as - burns,
necrotizing infections, brown recluse spider bites, osteomyelitis, and
diabetic ulcers
patient at risk for pressure injury - cardiovascular status -ANSWERS--
presence or absence of peripheral edema
-hand-vein filling in the dependent position
-neck-vein filling in the recumbent and sitting position
- weight gain or loss
patient at risk for pressure injury - cognition and mental status -
ANSWERS--level of consciousness
- orientation to time, place and person
- can the patient read a seven word sentence containing three syllables
or fewer
patient at risk for pressure injury - condition of skin -ANSWERS-- assess
skin cleanliness
- observe all skin areas, especially bony prominences and areas in
contact with the bed or other firm surfaces
- measure and record any redness or loss of integrity
- photograph areas of concern
- note presence of skin tenting over sternum and forehead
- note moistness of skin and mucous membranes
Answers (Verified Answers) Plus Rationales 2026 Q&A | Instant
Download Pdf
Stage 1 pressure ulcer -ANSWERS-- skin is intact
- area, usually over a bony prominence, red and does not blanch with
external pressure
Stage 2 pressure ulcer -ANSWERS-- skin is not intact
- there partial -thickness skin loss of the epidermis or dermis
- ulcer is superficial and maybe an abrasion, a blister (open or fluid-
filled, or a shallow crater)
Stage 3 pressure ulcer -ANSWERS-- skin loss is full thickness
subcutaneous tissue may be damaged or necrotic
- damage extends to fascia, bone, tendon and muscle
- undermining and tunneling may or may not be present
Stage 4 pressure ulcer -ANSWERS--Skin loss is full thickness with
exposed or palpable muscle, tendon, or bone
- often excludes undermining and tunneling
- sinus tracts may develop
- slough and eschar are often present or at least part of the wound
,Unstageable -ANSWERS-- skin loss is full thickness and the base is
completely covered with slough, or eschar, obscurring the true depth of
the wound
Wet to damp saline moistened gauze -ANSWERS-necrotic debris is
mechanically removed but with less trauma to healing tissue
Continuous wet gauze -ANSWERS-wound surface continually bathed
with wetting agent of choice, promoting dilution of viscous exudate and
softening of dry eschar
Topical enzyme preparations -ANSWERS-proteolytic action of thick,
adherent eschar causes breakdown of denatured protein and more
rapid separation of necrotic tissue
Moisture - retentive dressing -ANSWERS-Spontaneous separation of
necrotic tissue is promoted by autolysis
Wound - vac - negative pressure wound therapy -ANSWERS-can reduce
and or close chronic injuries by removing fluids or infectious materials,
enhancing granulation. Should be changed every 48 to 72 hours.
Hyperbaric - oxygen therapy (HBOT) -ANSWERS-administration of
oxygen under high pressure, raising tissue oxygen concentration.
, Usually received under limb life-threatening wounds such as - burns,
necrotizing infections, brown recluse spider bites, osteomyelitis, and
diabetic ulcers
patient at risk for pressure injury - cardiovascular status -ANSWERS--
presence or absence of peripheral edema
-hand-vein filling in the dependent position
-neck-vein filling in the recumbent and sitting position
- weight gain or loss
patient at risk for pressure injury - cognition and mental status -
ANSWERS--level of consciousness
- orientation to time, place and person
- can the patient read a seven word sentence containing three syllables
or fewer
patient at risk for pressure injury - condition of skin -ANSWERS-- assess
skin cleanliness
- observe all skin areas, especially bony prominences and areas in
contact with the bed or other firm surfaces
- measure and record any redness or loss of integrity
- photograph areas of concern
- note presence of skin tenting over sternum and forehead
- note moistness of skin and mucous membranes
