NR 224: Fundamentals of Nursing - Hygiene, Skin Integrity & Wound
Care |Chamberlain
1. When assessing a patient’s risk for pressure injuries using the Braden Scale,
which score indicates the highest risk?
A. 23
B. 9
C. 15
D. 18
Answer: B
Rationale: On the Braden Scale, lower scores indicate a higher risk for pressure injury
development. A score of 9 or less represents very high risk.
2. Which stage of pressure injury is characterized by non-blanchable erythema
of intact skin?
A. Stage 1
B. Stage 2
C. Stage 3
D. Deep Tissue Pressure Injury
Answer: A
Rationale: Stage 1 pressure injuries involve intact skin with a localized area of non-
blanchable erythema, which may appear differently in darkly pigmented skin.
,3. When performing perineal care for a female patient, the nurse should wipe in
which direction?
A. From back to front
B. In a circular motion
C. From front to back
D. Side to side
Answer: C
Rationale: Wiping from front to back (pubic area to anus) reduces the risk of transferring
fecal organisms to the urinary meatus, preventing UTIs.
4. A wound that has clear, watery plasma drainage is described as having what
type of exudate?
A. Sanguineous
B. Serosanguineous
C. Purulent
D. Serous
Answer: D
Rationale: Serous drainage is clear, watery plasma. Sanguineous is bright red blood;
serosanguineous is a pale, pink, watery mixture; purulent is thick yellow, green, or brown.
5. Which nutritional component is most essential for collagen synthesis and
epithelialization during wound healing?
A. Vitamin C
B. Vitamin K
C. Vitamin D
D. Vitamin B12
Answer: A
Rationale: Vitamin C (ascorbic acid) is vital for collagen synthesis, capillary wall integrity,
and fibroblast function in wound healing.
, 6. A patient’s wound shows partial-thickness skin loss with a visible basement
membrane or a blister. Which stage is this?
A. Stage 1
B. Unstageable
C. Stage 3
D. Stage 2
Answer: D
Rationale: Stage 2 involves partial-thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister.
7. What is the first action a nurse should take if a surgical wound undergoes
evisceration?
A. Call the surgeon immediately
B. Cover the protruding organs with sterile towels moistened with sterile normal saline
C. Push the organs back into the abdominal cavity
D. Place the patient in a High-Fowler’s position
Answer: B
Rationale: Evisceration is a medical emergency. The nurse must first protect the organs by
covering them with sterile, saline-moistened dressings to prevent drying and infection.
8. The nurse is caring for a diabetic patient. Which practice should the nurse
avoid during foot care?
A. Inspecting the feet daily
B. Soaking the feet in warm water
C. Applying lotion to the tops and bottoms of the feet
D. Cutting the toenails straight across
Answer: B
Rationale: Diabetic patients should avoid soaking their feet because it can lead to
maceration and skin breakdown, increasing the risk of infection.
Care |Chamberlain
1. When assessing a patient’s risk for pressure injuries using the Braden Scale,
which score indicates the highest risk?
A. 23
B. 9
C. 15
D. 18
Answer: B
Rationale: On the Braden Scale, lower scores indicate a higher risk for pressure injury
development. A score of 9 or less represents very high risk.
2. Which stage of pressure injury is characterized by non-blanchable erythema
of intact skin?
A. Stage 1
B. Stage 2
C. Stage 3
D. Deep Tissue Pressure Injury
Answer: A
Rationale: Stage 1 pressure injuries involve intact skin with a localized area of non-
blanchable erythema, which may appear differently in darkly pigmented skin.
,3. When performing perineal care for a female patient, the nurse should wipe in
which direction?
A. From back to front
B. In a circular motion
C. From front to back
D. Side to side
Answer: C
Rationale: Wiping from front to back (pubic area to anus) reduces the risk of transferring
fecal organisms to the urinary meatus, preventing UTIs.
4. A wound that has clear, watery plasma drainage is described as having what
type of exudate?
A. Sanguineous
B. Serosanguineous
C. Purulent
D. Serous
Answer: D
Rationale: Serous drainage is clear, watery plasma. Sanguineous is bright red blood;
serosanguineous is a pale, pink, watery mixture; purulent is thick yellow, green, or brown.
5. Which nutritional component is most essential for collagen synthesis and
epithelialization during wound healing?
A. Vitamin C
B. Vitamin K
C. Vitamin D
D. Vitamin B12
Answer: A
Rationale: Vitamin C (ascorbic acid) is vital for collagen synthesis, capillary wall integrity,
and fibroblast function in wound healing.
, 6. A patient’s wound shows partial-thickness skin loss with a visible basement
membrane or a blister. Which stage is this?
A. Stage 1
B. Unstageable
C. Stage 3
D. Stage 2
Answer: D
Rationale: Stage 2 involves partial-thickness loss of dermis presenting as a shallow open
ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister.
7. What is the first action a nurse should take if a surgical wound undergoes
evisceration?
A. Call the surgeon immediately
B. Cover the protruding organs with sterile towels moistened with sterile normal saline
C. Push the organs back into the abdominal cavity
D. Place the patient in a High-Fowler’s position
Answer: B
Rationale: Evisceration is a medical emergency. The nurse must first protect the organs by
covering them with sterile, saline-moistened dressings to prevent drying and infection.
8. The nurse is caring for a diabetic patient. Which practice should the nurse
avoid during foot care?
A. Inspecting the feet daily
B. Soaking the feet in warm water
C. Applying lotion to the tops and bottoms of the feet
D. Cutting the toenails straight across
Answer: B
Rationale: Diabetic patients should avoid soaking their feet because it can lead to
maceration and skin breakdown, increasing the risk of infection.
