WND 580 ACTUAL FINALS ANSWERS AND
QUESTIONS SET A+
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3
pressure injury on her coccyx with undermining. Which of the following risk factors is
most responsible for undermining in the pressure injury?
a. Shear from having the head of bed elevated to 45 degrees.
b. Friction from her turning from side to side.
c. Local infection in the wound.
d. Excess moisture in the wound bed. - ✔✔a. Shear from having the head of bed
elevated to 45 degrees.
✔✔A patient with paraplegia is in the wound clinic to have a new seating surface re-
evaluated. You notice a serous fluid filled blister on the left heel which you document as
a pressure injury in what Stage?
a. Stage 1.
b. Stage 2.
c. Stage 3.
d. Stage 4. - ✔✔b. Stage 2.
✔✔The care plan for the patient with a pressure risk assessment score (Braden Scale)
of 9 and on a therapeutic support surface should always include:
a. Maintaining HOB at 45 degrees or less.
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
c. Use an artificial sheepskin under the coccyx to prevent shear.
d. Avoid the use of absorbent under pads in patients with incontinence. - ✔✔b.
Reposition the patient every 2-4 hours depending upon tissue tolerance.
✔✔Mr. Lee was found lying at home on the floor. Upon admission, he has an intact,
nonblanchable, persistent purple discoloration over the coccyx. Which describes the
classification of his pressure injury?
, a. Deep tissue pressure injury.
b. Stage 1 pressure injury.
c. Unstageable.
d. Stage 3 pressure injury. - ✔✔a. Deep tissue pressure injury.
✔✔Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath.
Which of the following is considered a potential PRIMARY etiologic factor in the
development of a pressure injury for this patient?
a. Shear force
b. Short-term pressure force
c. Friction force
d. Presence of a medical device - ✔✔a. Shear force
✔✔Which area of the body is the MOST difficult to offload using a pressure
redistribution surface?
a. Sacrum.
b. Occiput.
c. Trochanter.
d. Heel. - ✔✔d. Heel.
✔✔What is recommend for a patient with a low Braden MOBILITY subscale score of 2
and MOISTURE subscale score of 1 to utilize a low air loss redistribution support
surface (BED)?
a. Stage 4 heel injury.
b. Stage 2 occiput injury.
c. Stage 3 sacral pressure injury.
d. IAD (incontinence associated dermatitis). - ✔✔c. Stage 3 sacral pressure injury.
✔✔Mr. Brown has mild to moderate urinary incontinence and limited mobility. Which of
the following will most likely occur due to the effects of prolonged moisture on his peri-
genital skin?
a. Thickened and strengthened collagen bonds.
b. Increased risk of mechanical injury.
c. Allergic reaction to incontinence pad.
d. Stabilization of skin normal flora. - ✔✔b. Increased risk of mechanical injury.
✔✔The wound care nurse is investigating why wound care treatments used in spinal
cord-injured (SCI) patients are less effective than those without SCI. One reason to
consider is:
QUESTIONS SET A+
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3
pressure injury on her coccyx with undermining. Which of the following risk factors is
most responsible for undermining in the pressure injury?
a. Shear from having the head of bed elevated to 45 degrees.
b. Friction from her turning from side to side.
c. Local infection in the wound.
d. Excess moisture in the wound bed. - ✔✔a. Shear from having the head of bed
elevated to 45 degrees.
✔✔A patient with paraplegia is in the wound clinic to have a new seating surface re-
evaluated. You notice a serous fluid filled blister on the left heel which you document as
a pressure injury in what Stage?
a. Stage 1.
b. Stage 2.
c. Stage 3.
d. Stage 4. - ✔✔b. Stage 2.
✔✔The care plan for the patient with a pressure risk assessment score (Braden Scale)
of 9 and on a therapeutic support surface should always include:
a. Maintaining HOB at 45 degrees or less.
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
c. Use an artificial sheepskin under the coccyx to prevent shear.
d. Avoid the use of absorbent under pads in patients with incontinence. - ✔✔b.
Reposition the patient every 2-4 hours depending upon tissue tolerance.
✔✔Mr. Lee was found lying at home on the floor. Upon admission, he has an intact,
nonblanchable, persistent purple discoloration over the coccyx. Which describes the
classification of his pressure injury?
, a. Deep tissue pressure injury.
b. Stage 1 pressure injury.
c. Unstageable.
d. Stage 3 pressure injury. - ✔✔a. Deep tissue pressure injury.
✔✔Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath.
Which of the following is considered a potential PRIMARY etiologic factor in the
development of a pressure injury for this patient?
a. Shear force
b. Short-term pressure force
c. Friction force
d. Presence of a medical device - ✔✔a. Shear force
✔✔Which area of the body is the MOST difficult to offload using a pressure
redistribution surface?
a. Sacrum.
b. Occiput.
c. Trochanter.
d. Heel. - ✔✔d. Heel.
✔✔What is recommend for a patient with a low Braden MOBILITY subscale score of 2
and MOISTURE subscale score of 1 to utilize a low air loss redistribution support
surface (BED)?
a. Stage 4 heel injury.
b. Stage 2 occiput injury.
c. Stage 3 sacral pressure injury.
d. IAD (incontinence associated dermatitis). - ✔✔c. Stage 3 sacral pressure injury.
✔✔Mr. Brown has mild to moderate urinary incontinence and limited mobility. Which of
the following will most likely occur due to the effects of prolonged moisture on his peri-
genital skin?
a. Thickened and strengthened collagen bonds.
b. Increased risk of mechanical injury.
c. Allergic reaction to incontinence pad.
d. Stabilization of skin normal flora. - ✔✔b. Increased risk of mechanical injury.
✔✔The wound care nurse is investigating why wound care treatments used in spinal
cord-injured (SCI) patients are less effective than those without SCI. One reason to
consider is:
