Chapter 48 Skin Integrity & Wound Care Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationales

1. A nurse is assessing a client with a pressure injury on the sacrum that presents with full-thickness skin loss and visible subcutaneous tissue. Which pressure injury stage is this? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4 Answer: C Rationale: Stage 3 pressure injuries involve full-thickness tissue loss with possible exposure of subcutaneous fat but not bone, tendon, or muscle. ________________________________________ 2. Which of the following best describes a stage 1 pressure injury? A) Non-blanchable redness over intact skin B) A blister filled with serous fluid C) Partial-thickness skin loss D) Open wound with slough Answer: A Rationale: Stage 1 is characterized by intact skin with non-blanchable redness in a localized area, often over a bony prominence. ________________________________________ 3. What is the primary purpose of repositioning a bedbound patient every 2 hours? A) Increase muscle strength B) Improve appetite C) Reduce the risk of pressure injury D) Prevent falls Answer: C Rationale: Frequent repositioning reduces prolonged pressure on bony prominences, thereby lowering the risk of pressure injuries. ________________________________________ 4. When assessing a wound, which finding is most indicative of infection? A) Pale wound edges B) Sanguineous drainage C) Foul odor and purulent exudate D) Scab formation Answer: C Rationale: Purulent drainage with foul odor suggests bacterial infection within the wound. ________________________________________ 5. Which intervention is most effective in preventing pressure injuries in a patient with limited mobility? A) Apply cold compresses to bony prominences B) Keep the head of bed elevated at 90 degrees C) Use a pressure redistribution surface D) Limit fluid intake Answer: C Rationale: Pressure redistribution surfaces help distribute weight more evenly and protect at-risk areas from skin breakdown. ________________________________________ 6. A nurse is assessing a surgical wound healing by primary intention. Which characteristic is expected? A) Large scar and slow healing B) Edges are approximated with minimal scarring C) Wound is left open and fills by granulation D) Significant tissue loss is present Answer: B Rationale: Healing by primary intention involves minimal tissue loss, with edges well approximated using sutures or staples. ________________________________________ 7. Which of the following patients is at the highest risk for impaired skin integrity? A) A 50-year-old with controlled diabetes B) A 45-year-old with an appendectomy C) A 70-year-old who is immobile and incontinent D) A 22-year-old marathon runner Answer: C Rationale: Immobility and incontinence significantly increase the risk of skin breakdown and pressure injury formation. ________________________________________ 8. Which nutrient is most critical for wound healing? A) Vitamin K B) Calcium C) Protein D) Sodium Answer: C Rationale: Protein plays a vital role in cell growth and repair, making it essential for wound healing. ________________________________________ 9. A nurse observes that a patient’s wound has new red, moist tissue that bleeds easily. How should this be interpreted? A) Presence of slough B) Evidence of necrosis C) Granulation tissue D) Sign of infection Answer: C Rationale: Granulation tissue is red, moist, and indicates healthy tissue growth during the healing process.