FUNDAMENTALS OF NURSING
CHAPTER 48: SKIN INTEGRITY AND
WOUND CARE EXAM 2025/2026
QUESTIONS AND VERIFIED ANSWERS
100% PASS < BRAND NEW VERSION>
1. The nurse is working on a medical-surgical unit that has been participating in a research
project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose
a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.
ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness are
unable to protect themselves. The patient may feel the pressure but may not understand what to
do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired
sensory perception, impaired mobility, shear, friction, and moisture are other predisposing
factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included
among the predisposing factors.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago.
The patient sustained a head injury and is unconscious. The nurse is able to identify that the
major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.
ANS: A
,Pressure is the main element that causes pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue
tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg,
this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure
over a short time and low pressure over a long time cause skin breakdown. Resistance (the
ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and
weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes
of pressure ulcers.
3. Which nursing observation would indicate that the patient was at risk for pressure ulcer
formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.
ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by making
it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and
fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for
skin breakdown because the skin is moistened and softened, causing maceration. Eating a
balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate
that the individual is at risk. A raised red rash on the leg again is a concern and can affect the
integrity of the skin, but it is located on the shin, which is not a high-risk area for skin
breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary
response is within normal limits.
4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a
patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is
observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
, d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage
and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures
even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage
such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse
notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer
would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving
epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister,
or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence.
With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles
are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or
muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of
the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light
ANS: D
CHAPTER 48: SKIN INTEGRITY AND
WOUND CARE EXAM 2025/2026
QUESTIONS AND VERIFIED ANSWERS
100% PASS < BRAND NEW VERSION>
1. The nurse is working on a medical-surgical unit that has been participating in a research
project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose
a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.
ANS: B
Patients who are confused or disoriented or who have changing levels of consciousness are
unable to protect themselves. The patient may feel the pressure but may not understand what to
do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired
sensory perception, impaired mobility, shear, friction, and moisture are other predisposing
factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included
among the predisposing factors.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago.
The patient sustained a head injury and is unconscious. The nurse is able to identify that the
major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.
ANS: A
,Pressure is the main element that causes pressure ulcers. Three pressure-related factors
contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue
tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg,
this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure
over a short time and low pressure over a long time cause skin breakdown. Resistance (the
ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and
weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes
of pressure ulcers.
3. Which nursing observation would indicate that the patient was at risk for pressure ulcer
formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.
ANS: B
The presence and duration of moisture on the skin increase the risk of ulcer formation by making
it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and
fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for
skin breakdown because the skin is moistened and softened, causing maceration. Eating a
balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate
that the individual is at risk. A raised red rash on the leg again is a concern and can affect the
integrity of the skin, but it is located on the shin, which is not a high-risk area for skin
breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary
response is within normal limits.
4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a
patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is
observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
, d. Stage III pressure ulcer
ANS: C
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage
and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures
even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage
such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse
notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer
would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving
epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister,
or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence.
With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles
are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or
muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of
the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light
ANS: D
