PRACTICE TEST BANK 2026 TESTED
QUESTIONS WITH ANSWERS GRADED A+
⩥ layers of the skin. Answer: epidermis, dermis (collagen)
⩥ body's defenses against infection. Answer: normal flora, inflammatory
response, immune response
⩥ comprehensive wound assessment. Answer: -ongoing assessment
from time of injury, wound care, any condition changes, and on
scheduled basis
-Important to include cause of injury, history of wound, treatment,
description, response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
⩥ Braden Scale. Answer: assesses risk for developing pressure ulcers;
includes patient's sensory perception, moisture, activity, mobility,
nutrition, friction and shear; the lower the number the higher the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
,19-23= generally not at risk
⩥ type 1 ulcers. Answer: skin is intact but may be red or pink and warm
to the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
⩥ type 2 ulcers. Answer: partial-thickness loss of dermis; shallow
broken skin; red-pink wound bed
⩥ type 3 ulcers. Answer: full-thickness tissue loss with visible fat
(subcutaneous layer); pale-yellow color; may include slough but does
not obstruct view of depth of injury
⩥ type 4 ulcers. Answer: full-thickness tissue loss with exposed bone,
muscle, or tendon. possible tunneling and undermining
⩥ unstageable pressure ulcer. Answer: base of ulcer covered by slough
and/or eschar in the wound bed so the depth is unknown; exudate;
⩥ deep tissue injury. 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.
,⩥ how should you clean a wound. Answer: from least to most
contaminated
⩥ eschar. Answer: black, brown or necrotic tissue in wound bed; needs
to be removed before healing
⩥ slough. Answer: stringy pale-yellowish tissue that lays in the wound
bed; needs to be removed before healing
⩥ if a patient has slough, eschar, and infectious exudate which one
would you be most concerned about. Answer: infectious exudate
⩥ factors influencing heat and cold tolerance. Answer: Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
⩥ assessment for pressure ulcers includes. Answer: location, staging
(depth), type and % of tissue in wound bed, wound dimensions
(including tunneling), exudate description (if odor is present), and
condition of surrounding skin
, ⩥ why is depth of an ulcer important. Answer: because the wound heals
inside-out
⩥ granulation tissue. Answer: good, fresh tissue that forms during the
healing of a wound (wound bed will be red, moist, and shiny)
⩥ How does a partial thickness wound heal?. Answer: by regeneration
(scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate serous
exudate. 1st 24hrs after wounding.
-epithelial proliferation (reproduction): starts at wound edges and
epidermal cells lining appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist
environment. in dry wound, the cells move down into a moist level
before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal
thickness and appear as dry, pink tissue
⩥ How does a full thickness wound heal?. Answer: by forming new
tissue/scar formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop
bleeding
-inflammation: damaged tissue and mast cells secrete histamine
(vasodilation of surrounding capillaries and movement of serum and
WBCs into damaged tissue)