Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
Assessment of M.J.'s right trochanter reveals a shallow open ulcer with a
red pink wound bed. This ulcer would be graded as:
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable. - Answer- b. A stage II ulcer: reveals partial thickness loss
of dermis presenting as a shallow open ulcer with a red pink wound bed,
without slough. It may also present as an intact or open/ruptured serum-
filled blister.
The skin on M.J.'s scapulae is intact but is boggy to touch and purple. You
identify this assessment finding as:
a. a stage I pressure ulcer.
b. a normal finding for an African-American patient.
c. unstageable as a result of ethnic variations in skin tone.
d. indicative of a high risk for pressure ulcer formation in that area.
- Answer- a. Stage I pressure ulcer: In a patient with darker skin tones,
you need to look for changes in skin color, such as skin that is darker
(purplish, brownish, bluish) than surrounding skin. You should also touch
the skin to feel its consistency. A boggy or edematous feel may indicate a
stage I pressure ulcer.
,Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
The pressure ulcer on M.J.'s left trochanter is covered with eschar. You
grade this ulcer as:
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable
. - Answer- e. Unstageable: When eschar is present, accurate staging of
the pressure ulcer is not possible until enough eschar is removed to expose
the base of the wound.
In planning care for M.J., you identify all the risk factors for pressure ulcers
that he has. Select those factors that you know apply to M.J. –
Answer- Older age
Contractures
Immobility
Incontinence
Neurologic disorders
Pain
THESE DO NOT APPLY:
NO: Anemia
NO: Diabetes mellitus
NO: Elevated body temperature
NO:Impaired circulation
NO: Low diastolic blood pressure (< 60)
NO: Mental deterioration
NO: Obesity
,Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
NO: Prolonged surgery
NO: Vascular disease
Using the Braden Scale, you complete M.J.'s risk assessment with the
following scores obtained: sensory perception - 2, moisture - 3, activity - 1,
mobility - 1, nutrition - 2, friction and shear - 1. TOTAL SCORE 10
- Answer- The patient's risk level is HIGH risk.
You measure and stage M.J.'s pressure ulcers and clean them with saline.
What equipment should you use to best cleanse the pressure ulcers
without causing trauma or damage to the wound?
A. Q-tips and 2 × 2 gauze
B. 4 × 4 gauze pads and a basin
C. 10-mL syringe with a 25-gauge needle
D. 30-mL syringe with a 19-gauge needle
- Answer- D. 30-mL syringe with a 19-gauge needle: It is important to use
enough irrigation pressure to adequately clean the pressure ulcer (4 to 15
psi) without causing trauma or damage to the wound. To obtain this
pressure, a 30-mL syringe and a 19-gauge needle can be used.
There is a moderate amount of yellow drainage from the sacral ulcer,
serous drainage from the right trochanter ulcer, and no drainage from the
left trochanter ulcer. There is black, necrotic tissue in the sacral ulcer, and
the left trochanter ulcer is covered with eschar. You recognize that further
care of these pressure ulcers requires:
A. removal of the necrotic tissue and eschar.
, Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
B. application of a dry dressing that will absorb any drainage.
C. the application of local antiseptic agents, such as povidone iodine.
D. the use of transparent polyurethane films to keep the wound moist.
- Answer- A. Removal of the necrotic tissue and eschar.
In order to establish a clean granulating base for healing, necrotic tissue
and eschar must be removed from the ulcer. The debridement method used
to remove necrotic tissue can be surgical, mechanical, enzymatic, or
autolytic and should be discussed with the health care provider. Eschar is
removed by cutting it away. Antiseptic solutions are cytotoxic and should
not be used to clean or soak pressure ulcers. Dry dressings should not be
used on newly granulating tissue, and transparent polyurethane films are
appropriate for superficial wounds without drainage.
Dietitian ROLE
- Answer- Evaluation of nutritional status
Recommendations for nutritional supplements
Home Health Aide ROLE
- Answer- Assist with personal care such as bathing and hygiene
Light housekeeping and meal preparation
Social Worker ROLE
- Answer- Assist with managing financial resources
Referral to volunteer MS agencies
Physician ROLE –
Answer- Medical monitoring of condition
Clinical Case Studies &
Answers | 2025/2026 Edition
Assessment of M.J.'s right trochanter reveals a shallow open ulcer with a
red pink wound bed. This ulcer would be graded as:
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable. - Answer- b. A stage II ulcer: reveals partial thickness loss
of dermis presenting as a shallow open ulcer with a red pink wound bed,
without slough. It may also present as an intact or open/ruptured serum-
filled blister.
The skin on M.J.'s scapulae is intact but is boggy to touch and purple. You
identify this assessment finding as:
a. a stage I pressure ulcer.
b. a normal finding for an African-American patient.
c. unstageable as a result of ethnic variations in skin tone.
d. indicative of a high risk for pressure ulcer formation in that area.
- Answer- a. Stage I pressure ulcer: In a patient with darker skin tones,
you need to look for changes in skin color, such as skin that is darker
(purplish, brownish, bluish) than surrounding skin. You should also touch
the skin to feel its consistency. A boggy or edematous feel may indicate a
stage I pressure ulcer.
,Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
The pressure ulcer on M.J.'s left trochanter is covered with eschar. You
grade this ulcer as:
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable
. - Answer- e. Unstageable: When eschar is present, accurate staging of
the pressure ulcer is not possible until enough eschar is removed to expose
the base of the wound.
In planning care for M.J., you identify all the risk factors for pressure ulcers
that he has. Select those factors that you know apply to M.J. –
Answer- Older age
Contractures
Immobility
Incontinence
Neurologic disorders
Pain
THESE DO NOT APPLY:
NO: Anemia
NO: Diabetes mellitus
NO: Elevated body temperature
NO:Impaired circulation
NO: Low diastolic blood pressure (< 60)
NO: Mental deterioration
NO: Obesity
,Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
NO: Prolonged surgery
NO: Vascular disease
Using the Braden Scale, you complete M.J.'s risk assessment with the
following scores obtained: sensory perception - 2, moisture - 3, activity - 1,
mobility - 1, nutrition - 2, friction and shear - 1. TOTAL SCORE 10
- Answer- The patient's risk level is HIGH risk.
You measure and stage M.J.'s pressure ulcers and clean them with saline.
What equipment should you use to best cleanse the pressure ulcers
without causing trauma or damage to the wound?
A. Q-tips and 2 × 2 gauze
B. 4 × 4 gauze pads and a basin
C. 10-mL syringe with a 25-gauge needle
D. 30-mL syringe with a 19-gauge needle
- Answer- D. 30-mL syringe with a 19-gauge needle: It is important to use
enough irrigation pressure to adequately clean the pressure ulcer (4 to 15
psi) without causing trauma or damage to the wound. To obtain this
pressure, a 30-mL syringe and a 19-gauge needle can be used.
There is a moderate amount of yellow drainage from the sacral ulcer,
serous drainage from the right trochanter ulcer, and no drainage from the
left trochanter ulcer. There is black, necrotic tissue in the sacral ulcer, and
the left trochanter ulcer is covered with eschar. You recognize that further
care of these pressure ulcers requires:
A. removal of the necrotic tissue and eschar.
, Medical-Surgical Nursing I:
Clinical Case Studies &
Answers | 2025/2026 Edition
B. application of a dry dressing that will absorb any drainage.
C. the application of local antiseptic agents, such as povidone iodine.
D. the use of transparent polyurethane films to keep the wound moist.
- Answer- A. Removal of the necrotic tissue and eschar.
In order to establish a clean granulating base for healing, necrotic tissue
and eschar must be removed from the ulcer. The debridement method used
to remove necrotic tissue can be surgical, mechanical, enzymatic, or
autolytic and should be discussed with the health care provider. Eschar is
removed by cutting it away. Antiseptic solutions are cytotoxic and should
not be used to clean or soak pressure ulcers. Dry dressings should not be
used on newly granulating tissue, and transparent polyurethane films are
appropriate for superficial wounds without drainage.
Dietitian ROLE
- Answer- Evaluation of nutritional status
Recommendations for nutritional supplements
Home Health Aide ROLE
- Answer- Assist with personal care such as bathing and hygiene
Light housekeeping and meal preparation
Social Worker ROLE
- Answer- Assist with managing financial resources
Referral to volunteer MS agencies
Physician ROLE –
Answer- Medical monitoring of condition
