PRESSURE INJURIES AND WOUND HEALING: ADVANCED PRACTICE
ASSESSMENT — 150 HIGH-YIELD MCQ EXAMINATION WITH ANSWERS
AND RATIONALES (2026–2027 ACADEMIC SESSION)
1. A nurse is assessing a patient with a pressure injury. The wound bed is covered by a thick layer of
black, dry, adherent eschar, and the true depth cannot be determined. How should this injury be
classified?
A. Stage 3
B. Stage 4
C. Unstageable
D. Deep tissue pressure injury
Correct Answer:C
Rationale: Unstageable pressure injury is defined as full-thickness tissue loss in which the wound base
is obscured by slough or eschar, making true depth determination impossible until debridement occurs .
2. A patient has an intact area of purple/maroon discoloration over the sacrum that is painful and boggy
to palpation. What is the correct classification?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue pressure injury
D. Unstageable pressure injury
Correct Answer:C
Rationale: Deep tissue pressure injury (DTPI) presents as intact or non-intact skin with localized purple
or maroon discoloration or a blood-filled blister, indicating damage to underlying soft tissue from
pressure and/or shear .
,3. A nurse documents a pressure injury as having full -thickness skin loss with visible subcutaneous fat
but no exposed bone, tendon, or muscle. What stage is this?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer:C
Rationale: Stage 3 pressure injury involves full-thickness skin loss extending into subcutaneous tissue,
with visible adipose tissue but no exposure of bone, tendon, or muscle .
4. Which phase of wound healing is characterized by vasoconstriction, platelet aggregation, and fibrin
clot formation?
A. Inflammatory phase
B. Hemostasis phase
C. Proliferative phase
D. Maturation phase
Correct Answer:B
Rationale: Hemostasis is the immediate response to injury, occurring within seconds to minutes. It
involves vasoconstriction, platelet aggregation, and fibrin clot formation to stabilize the wound bed .
5. A wound care nurse assesses a wound with a channe l extending from the wound base into
surrounding tissue. How should this be documented?
A. Undermining
B. Tunneling
C. Epibole
,D. Maceration
Correct Answer:B
Rationale: Tunneling describes a channel or tract that extends from the wound base into surrounding
tissue in any direction. It should be documented with depth and direction using clock face references .
6. According to the Braden Scale, which domain assesses the patient's ability to respond meaningfully to
pressure-related discomfort?
A. Moisture
B. Activity
C. Sensory perception
D. Nutrition
Correct Answer:C
Rationale: The sensory perception domain evaluates the patient's neurological awareness and ability to
detect and respond to pressure-related discomfort, which is essential for pressure injury prevention .
7. A patient scores 11 on the Braden Scale. How should this be interpreted?
A. No risk
B. Mild risk
C. Moderate risk
D. High risk
Correct Answer:D
Rationale: A Braden Score of 10–12 indicates high risk for pressure injury development, requiring
aggressive pressure redistribution, moisture management, and frequent turning schedules .
, 8. What is the primary benefit of maintaining a moist wound environment?
A. Increased scab formation
B. Enhanced epithelial cell migration
C. Reduced oxygen diffusion
D. Complete elimination of exudate
Correct Answer:B
Rationale: Moist wound environments support epithelial migration, angiogenesis, and autolytic
debridement, accelerating healing. Dry environments promote scab formation, which acts as a barrier to
epithelialization .
9. A patient with a neuropathic plantar foot ulcer has palpable pedal pulses. What is the gold standard
intervention to promote healing?
A. Application of hydrocolloid dressing
B. Systemic antibiotics
C. Total contact casting
D. Compression therapy
Correct Answer:C
Rationale: Total contact casting is the gold standard for offloading neuropathic plantar foot ulcers. It
redistributes weight and reduces mechanical stress on the ulcer, which is essential for healing in
patients with neuropathy .
10. Which dressing type is most appropriate for a heavily exudating wound?
A. Transparent film
B. Hydrocolloid
C. Calcium alginate
ASSESSMENT — 150 HIGH-YIELD MCQ EXAMINATION WITH ANSWERS
AND RATIONALES (2026–2027 ACADEMIC SESSION)
1. A nurse is assessing a patient with a pressure injury. The wound bed is covered by a thick layer of
black, dry, adherent eschar, and the true depth cannot be determined. How should this injury be
classified?
A. Stage 3
B. Stage 4
C. Unstageable
D. Deep tissue pressure injury
Correct Answer:C
Rationale: Unstageable pressure injury is defined as full-thickness tissue loss in which the wound base
is obscured by slough or eschar, making true depth determination impossible until debridement occurs .
2. A patient has an intact area of purple/maroon discoloration over the sacrum that is painful and boggy
to palpation. What is the correct classification?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue pressure injury
D. Unstageable pressure injury
Correct Answer:C
Rationale: Deep tissue pressure injury (DTPI) presents as intact or non-intact skin with localized purple
or maroon discoloration or a blood-filled blister, indicating damage to underlying soft tissue from
pressure and/or shear .
,3. A nurse documents a pressure injury as having full -thickness skin loss with visible subcutaneous fat
but no exposed bone, tendon, or muscle. What stage is this?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct Answer:C
Rationale: Stage 3 pressure injury involves full-thickness skin loss extending into subcutaneous tissue,
with visible adipose tissue but no exposure of bone, tendon, or muscle .
4. Which phase of wound healing is characterized by vasoconstriction, platelet aggregation, and fibrin
clot formation?
A. Inflammatory phase
B. Hemostasis phase
C. Proliferative phase
D. Maturation phase
Correct Answer:B
Rationale: Hemostasis is the immediate response to injury, occurring within seconds to minutes. It
involves vasoconstriction, platelet aggregation, and fibrin clot formation to stabilize the wound bed .
5. A wound care nurse assesses a wound with a channe l extending from the wound base into
surrounding tissue. How should this be documented?
A. Undermining
B. Tunneling
C. Epibole
,D. Maceration
Correct Answer:B
Rationale: Tunneling describes a channel or tract that extends from the wound base into surrounding
tissue in any direction. It should be documented with depth and direction using clock face references .
6. According to the Braden Scale, which domain assesses the patient's ability to respond meaningfully to
pressure-related discomfort?
A. Moisture
B. Activity
C. Sensory perception
D. Nutrition
Correct Answer:C
Rationale: The sensory perception domain evaluates the patient's neurological awareness and ability to
detect and respond to pressure-related discomfort, which is essential for pressure injury prevention .
7. A patient scores 11 on the Braden Scale. How should this be interpreted?
A. No risk
B. Mild risk
C. Moderate risk
D. High risk
Correct Answer:D
Rationale: A Braden Score of 10–12 indicates high risk for pressure injury development, requiring
aggressive pressure redistribution, moisture management, and frequent turning schedules .
, 8. What is the primary benefit of maintaining a moist wound environment?
A. Increased scab formation
B. Enhanced epithelial cell migration
C. Reduced oxygen diffusion
D. Complete elimination of exudate
Correct Answer:B
Rationale: Moist wound environments support epithelial migration, angiogenesis, and autolytic
debridement, accelerating healing. Dry environments promote scab formation, which acts as a barrier to
epithelialization .
9. A patient with a neuropathic plantar foot ulcer has palpable pedal pulses. What is the gold standard
intervention to promote healing?
A. Application of hydrocolloid dressing
B. Systemic antibiotics
C. Total contact casting
D. Compression therapy
Correct Answer:C
Rationale: Total contact casting is the gold standard for offloading neuropathic plantar foot ulcers. It
redistributes weight and reduces mechanical stress on the ulcer, which is essential for healing in
patients with neuropathy .
10. Which dressing type is most appropriate for a heavily exudating wound?
A. Transparent film
B. Hydrocolloid
C. Calcium alginate
