NSG-300 Exam 2 COMPLETE
QUESTIONS WITH 100% RATED
CORRECT ANSWERS | GRADED A+|
2025 LATEST UPDATED
What are 3 pressure related factors that contribute to pressure ulcer development? -
CORRECT ANSWER ✅✅✅1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - CORRECT ANSWER ✅✅✅If
pressure applied over a capillary exceeds normal capillary pressure and the vessel is
occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - CORRECT ANSWER
✅✅✅tissue death
Does blanching occur in dark skinned patients? - CORRECT ANSWER ✅✅✅No,
blanching does not occur but color, texture and temp may differ from surrounding
area
What does pressure duration assess? - CORRECT ANSWER ✅✅✅Low and
extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - CORRECT ANSWER ✅✅✅the ability of tissue to
endure pressure which is dependent on the integrity of the tissue and supporting
structures
What are risk factors of pressure injuries? - CORRECT ANSWER ✅✅✅◦Impaired
sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - CORRECT
ANSWER ✅✅✅Wound location, staging, type and approximate percentage of
tissue in wound bed, wound dimensions (sinus tracts and tunneling), exudate
description and condition of surrounding skin
,stage 1 pressure injury - CORRECT ANSWER ✅✅✅Intact skin with
nonblanchable redness
stage 2 pressure injury - CORRECT ANSWER ✅✅✅partial thickness skin loss
involving epidermis, dermis or both and, shallow abrasion or open blister looking
stage 3 pressure injury - CORRECT ANSWER ✅✅✅full thickness skin loss
extending to SQ, crater looking
stage 4 pressure injury - CORRECT ANSWER ✅✅✅full thickness with exposed
bone, muscle or tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - CORRECT
ANSWER ✅✅✅They may have slough, undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should the
student nurse expect to see? - CORRECT ANSWER ✅✅✅A yellow or white,
stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the
student nurse expect to see? - CORRECT ANSWER ✅✅✅brown or black
necrotic tissue
Unstageable/Unclassified Pressure Ulcer - CORRECT ANSWER ✅✅✅Tissue
loss but depth unknown because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it will
heal on its own". What education should the nurse provide? - CORRECT ANSWER
✅✅✅Slough and eschar must be removed by a clinician to determine the stage
and in order for healing to occur
suspected deep tissue injury - CORRECT ANSWER ✅✅✅Purple or maroon
localized area of discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear. Depth unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What
should the student nurse expect to see? - CORRECT ANSWER ✅✅✅Red, moist
tissue which indicates progression toward healing
What should the nurse document when assessing exudate? - CORRECT ANSWER
✅✅✅Amount, color, consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does
this indicate? - CORRECT ANSWER ✅✅✅The presence of infection
What should the nurse look for when assessing the periwound area? Why is it
important? - CORRECT ANSWER ✅✅✅Redness, warmth, signs of maceration
and pain
, - presence of any of these factors indicates wound deterioration
Why is wound classification important? - CORRECT ANSWER ✅✅✅Allows a
nurse to understand the risks associated with a wound and implications for healing
How does a partial thickness wound heal? - CORRECT ANSWER ✅✅✅Heals by
regeneration
How does a full thickness would heal? - CORRECT ANSWER ✅✅✅Heals by
forming new tissue which takes longer
What are the three components involved in the healing process of a partial thickness
wound? - CORRECT ANSWER ✅✅✅Inflammatory response, epithelial
proliferation and migration, and reestablishment of epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal
quickly. What education should the nurse provide to the patient? - CORRECT
ANSWER ✅✅✅Wounds heal faster in moist environments because epidermal
cells only migrate across moist surfaces.
Reestablishment of the epidermal layers - CORRECT ANSWER ✅✅✅New
epithelium is only a few cells thick. Cells slowly reestablish normal thickness and
appear as dry, pink tissue
What are the four stages involved in the healing process of a full thickness wound? -
CORRECT ANSWER ✅✅✅Hemostasis, inflammation, proliferation and
maturation
Primary intention healing - CORRECT ANSWER ✅✅✅The skin edges are
approximated, or closed, and the risk of infection is low. Healing occurs quickly, with
minimal scar formation, as long as infection and secondary breakdown are
prevented
Secondary infection healing - CORRECT ANSWER ✅✅✅Wound is left open until
it becomes filed by scar tissue. It takes longer for a wound to heal by secondary
intention increasing the chance of infection
hemorrhage - CORRECT ANSWER ✅✅✅bleeding from a wound site is normal
during and immediately after initial trauma
A nurse suspects internal bleeding. How would the nurses assess the patient to
confirm her findings? - CORRECT ANSWER ✅✅✅By assessing for distention or
swelling of the affected body part, change in type and amount of drainage from a
surgical drain r signs of hypovolemic shock
Hematoma - CORRECT ANSWER ✅✅✅localized collection of blood underneath
the tissue
QUESTIONS WITH 100% RATED
CORRECT ANSWERS | GRADED A+|
2025 LATEST UPDATED
What are 3 pressure related factors that contribute to pressure ulcer development? -
CORRECT ANSWER ✅✅✅1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - CORRECT ANSWER ✅✅✅If
pressure applied over a capillary exceeds normal capillary pressure and the vessel is
occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - CORRECT ANSWER
✅✅✅tissue death
Does blanching occur in dark skinned patients? - CORRECT ANSWER ✅✅✅No,
blanching does not occur but color, texture and temp may differ from surrounding
area
What does pressure duration assess? - CORRECT ANSWER ✅✅✅Low and
extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - CORRECT ANSWER ✅✅✅the ability of tissue to
endure pressure which is dependent on the integrity of the tissue and supporting
structures
What are risk factors of pressure injuries? - CORRECT ANSWER ✅✅✅◦Impaired
sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - CORRECT
ANSWER ✅✅✅Wound location, staging, type and approximate percentage of
tissue in wound bed, wound dimensions (sinus tracts and tunneling), exudate
description and condition of surrounding skin
,stage 1 pressure injury - CORRECT ANSWER ✅✅✅Intact skin with
nonblanchable redness
stage 2 pressure injury - CORRECT ANSWER ✅✅✅partial thickness skin loss
involving epidermis, dermis or both and, shallow abrasion or open blister looking
stage 3 pressure injury - CORRECT ANSWER ✅✅✅full thickness skin loss
extending to SQ, crater looking
stage 4 pressure injury - CORRECT ANSWER ✅✅✅full thickness with exposed
bone, muscle or tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries share? - CORRECT
ANSWER ✅✅✅They may have slough, undermining and tunneling present
A nurse states slough is present in a stage 3 pressure injury. What should the
student nurse expect to see? - CORRECT ANSWER ✅✅✅A yellow or white,
stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the
student nurse expect to see? - CORRECT ANSWER ✅✅✅brown or black
necrotic tissue
Unstageable/Unclassified Pressure Ulcer - CORRECT ANSWER ✅✅✅Tissue
loss but depth unknown because wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it will
heal on its own". What education should the nurse provide? - CORRECT ANSWER
✅✅✅Slough and eschar must be removed by a clinician to determine the stage
and in order for healing to occur
suspected deep tissue injury - CORRECT ANSWER ✅✅✅Purple or maroon
localized area of discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear. Depth unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What
should the student nurse expect to see? - CORRECT ANSWER ✅✅✅Red, moist
tissue which indicates progression toward healing
What should the nurse document when assessing exudate? - CORRECT ANSWER
✅✅✅Amount, color, consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does
this indicate? - CORRECT ANSWER ✅✅✅The presence of infection
What should the nurse look for when assessing the periwound area? Why is it
important? - CORRECT ANSWER ✅✅✅Redness, warmth, signs of maceration
and pain
, - presence of any of these factors indicates wound deterioration
Why is wound classification important? - CORRECT ANSWER ✅✅✅Allows a
nurse to understand the risks associated with a wound and implications for healing
How does a partial thickness wound heal? - CORRECT ANSWER ✅✅✅Heals by
regeneration
How does a full thickness would heal? - CORRECT ANSWER ✅✅✅Heals by
forming new tissue which takes longer
What are the three components involved in the healing process of a partial thickness
wound? - CORRECT ANSWER ✅✅✅Inflammatory response, epithelial
proliferation and migration, and reestablishment of epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal
quickly. What education should the nurse provide to the patient? - CORRECT
ANSWER ✅✅✅Wounds heal faster in moist environments because epidermal
cells only migrate across moist surfaces.
Reestablishment of the epidermal layers - CORRECT ANSWER ✅✅✅New
epithelium is only a few cells thick. Cells slowly reestablish normal thickness and
appear as dry, pink tissue
What are the four stages involved in the healing process of a full thickness wound? -
CORRECT ANSWER ✅✅✅Hemostasis, inflammation, proliferation and
maturation
Primary intention healing - CORRECT ANSWER ✅✅✅The skin edges are
approximated, or closed, and the risk of infection is low. Healing occurs quickly, with
minimal scar formation, as long as infection and secondary breakdown are
prevented
Secondary infection healing - CORRECT ANSWER ✅✅✅Wound is left open until
it becomes filed by scar tissue. It takes longer for a wound to heal by secondary
intention increasing the chance of infection
hemorrhage - CORRECT ANSWER ✅✅✅bleeding from a wound site is normal
during and immediately after initial trauma
A nurse suspects internal bleeding. How would the nurses assess the patient to
confirm her findings? - CORRECT ANSWER ✅✅✅By assessing for distention or
swelling of the affected body part, change in type and amount of drainage from a
surgical drain r signs of hypovolemic shock
Hematoma - CORRECT ANSWER ✅✅✅localized collection of blood underneath
the tissue
