Page |1
NU 136 EXAM 2 ACTUAL EXAM [ QUESTION 1- 200]
AND ANSWERS UPDATED 2026/2027| 100%
VERIFIED|DETAILED RATIONALES –PASS
GUARANTEED A+ GRADED |INSTANT DOWNLOAD
Introduction:
**This NU 136 Exam 2 Wound Care practice set provides comprehensive preparation for
assessment and management of patients with acute and chronic wounds. The questions
emphasize wound assessment, pressure injuries, skin integrity, wound healing, infection
prevention, wound classification, dressing selection, nutrition, documentation, and evidence-
based nursing interventions. Candidates will encounter clinical scenarios requiring
prioritization, interpretation of wound findings, recognition of complications, and selection of
appropriate nursing actions. The practice questions are designed to strengthen clinical judgment
rather than encourage memorization. Each item includes a detailed rationale explaining the
correct answer and the reasoning behind the distractors, allowing learners to identify knowledge
gaps and reinforce essential concepts. Particular attention is given to risk assessment, staging
principles, wound characteristics, factors that delay healing, infection indicators, and safe
wound-care techniques. Working through these questions systematically can help students
develop confidence in applying wound-care principles to realistic patient situations and improve
their ability to recognize the most appropriate nursing intervention in examination settings._
Core Domains Covered:
1. Wound Assessment and Documentation — Systematic assessment of wound location, size,
depth, tissue type, drainage, odor, surrounding skin, pain, and healing progress.
2. Pressure Injuries — Risk factors, prevention, classification, staging concepts, repositioning,
support surfaces, and evidence-based management.
3. Wound Healing — Phases of healing and physiologic factors affecting tissue repair.
4. Infection and Wound Complications — Recognition of local and systemic infection, wound
deterioration, dehiscence, and other complications.
5. Wound Cleansing and Dressings — Selection and safe application of cleansing solutions,
dressings, and wound-care techniques.
6. Nutrition and Tissue Integrity — Nutritional requirements and assessment of factors
affecting wound healing.
7. Patient Safety, Prevention, and Education — Skin protection, pressure redistribution,
patient teaching, and prevention of wound recurrence.
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8. Clinical Judgment and Prioritization — Applying assessment findings to determine urgent
interventions and appropriate nursing priorities.
QUESTIONS
Question 1
A 72-year-old patient who has been immobile in bed for several days develops persistent redness
over the sacral area. The skin remains intact, but the erythema does not blanch when gentle
pressure is applied. Which finding is most consistent with this assessment?
A) Stage 2 pressure injury
B) Stage 1 pressure injury
C) Stage 3 pressure injury
D) Moisture-associated skin damage
Rationale: A stage 1 pressure injury involves intact skin with persistent nonblanchable erythema
over a localized area. Stage 2 involves partial-thickness skin loss with exposed dermis. Stage 3
involves full-thickness skin loss, while moisture-associated skin damage results primarily from
prolonged exposure to moisture rather than sustained pressure. Early recognition allows
preventive interventions before tissue damage progresses.
Question 2
A nurse is assessing a wound and notes a wound bed containing healthy, moist, red tissue that
bleeds easily when gently touched. Which tissue is the nurse observing?
A) Slough
B) Eschar
C) Granulation tissue
D) Necrotic tissue
Rationale: Granulation tissue is healthy vascular tissue that develops during the proliferative
phase of healing. It is typically red or pink and may bleed easily because of its rich capillary
supply. Slough is usually yellow, tan, or gray devitalized tissue, while eschar is thick, dark
necrotic tissue. Necrotic tissue does not represent healthy healing tissue.
Question 3
A patient with limited mobility is at high risk for pressure injury. Which nursing intervention is
most effective for reducing prolonged pressure?
A) Massage reddened bony prominences
B) Keep the patient in one position to minimize friction
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C) Reposition the patient regularly and use pressure-redistributing surfaces
D) Apply powder to all areas exposed to pressure
Rationale: Regular repositioning combined with appropriate pressure-redistributing surfaces
reduces sustained pressure and protects tissue perfusion. Massaging reddened areas can further
injure compromised tissue. Keeping a patient in one position increases pressure duration.
Powder does not redistribute pressure and may contribute to moisture-related problems if used
improperly.
Question 4
Which assessment finding should cause the nurse to suspect wound infection?
A) Small amount of clear serous drainage
B) Pink granulation tissue
C) Increasing pain, purulent drainage, and spreading erythema
D) Slight itching around a healing incision
Rationale: Increasing pain, purulent drainage, and spreading erythema are concerning for
infection, particularly when these findings represent a change from baseline. Serous drainage
and healthy granulation can occur during normal healing. Mild itching may occur during
healing but is not by itself diagnostic of infection.
Question 5
A nurse is documenting a wound that measures 4 centimeters long, 2 centimeters wide, and 1
centimeter deep. Which documentation is most appropriate?
A) Wound is approximately medium-sized
B) Wound is deep and infected
C) Wound measures 4 cm × 2 cm × 1 cm
D) Wound appears moderately severe
Rationale: Wound documentation should use objective, measurable findings rather than vague
descriptions. Length, width, and depth should be recorded consistently, preferably using the
same measurement technique over time. Terms such as “medium-sized,” “deep,” or
“moderately severe” are subjective and do not provide sufficient clinical detail.
Question 6
A patient with a chronic wound has poor nutritional intake. Which nutrient is particularly
important for collagen synthesis and wound healing?
A) Sodium
B) Protein
, Page |4
C) Cholesterol
D) Fluoride
Rationale: Protein provides amino acids required for tissue repair, immune function, and
collagen formation. Inadequate protein intake can delay wound healing. Sodium, cholesterol,
and fluoride do not serve as the primary nutritional substrate for collagen synthesis.
Question 7
Which phase of wound healing is characterized by vasoconstriction followed by clot formation
and hemostasis?
A) Remodeling
B) Proliferative
C) Hemostasis
D) Maturation
Rationale: Hemostasis begins immediately after tissue injury and involves vascular responses
and clot formation to control bleeding. The inflammatory phase follows. The proliferative phase
involves granulation tissue, angiogenesis, and epithelialization, while remodeling strengthens
the repaired tissue over time.
Question 8
A patient has a pressure injury with full-thickness skin loss and visible adipose tissue. Tendon,
muscle, cartilage, and bone are not exposed. How should the injury be classified?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Rationale: Stage 3 pressure injury involves full-thickness skin loss in which adipose tissue may
be visible. Deeper structures such as fascia, muscle, tendon, cartilage, or bone are not exposed.
Stage 2 is partial-thickness skin loss, whereas stage 4 involves exposed or directly palpable
deeper structures.
Question 9
A nurse discovers that a patient's wound has separated along the incision after abdominal
surgery. Which complication has occurred?
A) Hematoma
B) Seroma
C) Dehiscence
D) Granulation
NU 136 EXAM 2 ACTUAL EXAM [ QUESTION 1- 200]
AND ANSWERS UPDATED 2026/2027| 100%
VERIFIED|DETAILED RATIONALES –PASS
GUARANTEED A+ GRADED |INSTANT DOWNLOAD
Introduction:
**This NU 136 Exam 2 Wound Care practice set provides comprehensive preparation for
assessment and management of patients with acute and chronic wounds. The questions
emphasize wound assessment, pressure injuries, skin integrity, wound healing, infection
prevention, wound classification, dressing selection, nutrition, documentation, and evidence-
based nursing interventions. Candidates will encounter clinical scenarios requiring
prioritization, interpretation of wound findings, recognition of complications, and selection of
appropriate nursing actions. The practice questions are designed to strengthen clinical judgment
rather than encourage memorization. Each item includes a detailed rationale explaining the
correct answer and the reasoning behind the distractors, allowing learners to identify knowledge
gaps and reinforce essential concepts. Particular attention is given to risk assessment, staging
principles, wound characteristics, factors that delay healing, infection indicators, and safe
wound-care techniques. Working through these questions systematically can help students
develop confidence in applying wound-care principles to realistic patient situations and improve
their ability to recognize the most appropriate nursing intervention in examination settings._
Core Domains Covered:
1. Wound Assessment and Documentation — Systematic assessment of wound location, size,
depth, tissue type, drainage, odor, surrounding skin, pain, and healing progress.
2. Pressure Injuries — Risk factors, prevention, classification, staging concepts, repositioning,
support surfaces, and evidence-based management.
3. Wound Healing — Phases of healing and physiologic factors affecting tissue repair.
4. Infection and Wound Complications — Recognition of local and systemic infection, wound
deterioration, dehiscence, and other complications.
5. Wound Cleansing and Dressings — Selection and safe application of cleansing solutions,
dressings, and wound-care techniques.
6. Nutrition and Tissue Integrity — Nutritional requirements and assessment of factors
affecting wound healing.
7. Patient Safety, Prevention, and Education — Skin protection, pressure redistribution,
patient teaching, and prevention of wound recurrence.
,Page |2
8. Clinical Judgment and Prioritization — Applying assessment findings to determine urgent
interventions and appropriate nursing priorities.
QUESTIONS
Question 1
A 72-year-old patient who has been immobile in bed for several days develops persistent redness
over the sacral area. The skin remains intact, but the erythema does not blanch when gentle
pressure is applied. Which finding is most consistent with this assessment?
A) Stage 2 pressure injury
B) Stage 1 pressure injury
C) Stage 3 pressure injury
D) Moisture-associated skin damage
Rationale: A stage 1 pressure injury involves intact skin with persistent nonblanchable erythema
over a localized area. Stage 2 involves partial-thickness skin loss with exposed dermis. Stage 3
involves full-thickness skin loss, while moisture-associated skin damage results primarily from
prolonged exposure to moisture rather than sustained pressure. Early recognition allows
preventive interventions before tissue damage progresses.
Question 2
A nurse is assessing a wound and notes a wound bed containing healthy, moist, red tissue that
bleeds easily when gently touched. Which tissue is the nurse observing?
A) Slough
B) Eschar
C) Granulation tissue
D) Necrotic tissue
Rationale: Granulation tissue is healthy vascular tissue that develops during the proliferative
phase of healing. It is typically red or pink and may bleed easily because of its rich capillary
supply. Slough is usually yellow, tan, or gray devitalized tissue, while eschar is thick, dark
necrotic tissue. Necrotic tissue does not represent healthy healing tissue.
Question 3
A patient with limited mobility is at high risk for pressure injury. Which nursing intervention is
most effective for reducing prolonged pressure?
A) Massage reddened bony prominences
B) Keep the patient in one position to minimize friction
,Page |3
C) Reposition the patient regularly and use pressure-redistributing surfaces
D) Apply powder to all areas exposed to pressure
Rationale: Regular repositioning combined with appropriate pressure-redistributing surfaces
reduces sustained pressure and protects tissue perfusion. Massaging reddened areas can further
injure compromised tissue. Keeping a patient in one position increases pressure duration.
Powder does not redistribute pressure and may contribute to moisture-related problems if used
improperly.
Question 4
Which assessment finding should cause the nurse to suspect wound infection?
A) Small amount of clear serous drainage
B) Pink granulation tissue
C) Increasing pain, purulent drainage, and spreading erythema
D) Slight itching around a healing incision
Rationale: Increasing pain, purulent drainage, and spreading erythema are concerning for
infection, particularly when these findings represent a change from baseline. Serous drainage
and healthy granulation can occur during normal healing. Mild itching may occur during
healing but is not by itself diagnostic of infection.
Question 5
A nurse is documenting a wound that measures 4 centimeters long, 2 centimeters wide, and 1
centimeter deep. Which documentation is most appropriate?
A) Wound is approximately medium-sized
B) Wound is deep and infected
C) Wound measures 4 cm × 2 cm × 1 cm
D) Wound appears moderately severe
Rationale: Wound documentation should use objective, measurable findings rather than vague
descriptions. Length, width, and depth should be recorded consistently, preferably using the
same measurement technique over time. Terms such as “medium-sized,” “deep,” or
“moderately severe” are subjective and do not provide sufficient clinical detail.
Question 6
A patient with a chronic wound has poor nutritional intake. Which nutrient is particularly
important for collagen synthesis and wound healing?
A) Sodium
B) Protein
, Page |4
C) Cholesterol
D) Fluoride
Rationale: Protein provides amino acids required for tissue repair, immune function, and
collagen formation. Inadequate protein intake can delay wound healing. Sodium, cholesterol,
and fluoride do not serve as the primary nutritional substrate for collagen synthesis.
Question 7
Which phase of wound healing is characterized by vasoconstriction followed by clot formation
and hemostasis?
A) Remodeling
B) Proliferative
C) Hemostasis
D) Maturation
Rationale: Hemostasis begins immediately after tissue injury and involves vascular responses
and clot formation to control bleeding. The inflammatory phase follows. The proliferative phase
involves granulation tissue, angiogenesis, and epithelialization, while remodeling strengthens
the repaired tissue over time.
Question 8
A patient has a pressure injury with full-thickness skin loss and visible adipose tissue. Tendon,
muscle, cartilage, and bone are not exposed. How should the injury be classified?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Rationale: Stage 3 pressure injury involves full-thickness skin loss in which adipose tissue may
be visible. Deeper structures such as fascia, muscle, tendon, cartilage, or bone are not exposed.
Stage 2 is partial-thickness skin loss, whereas stage 4 involves exposed or directly palpable
deeper structures.
Question 9
A nurse discovers that a patient's wound has separated along the incision after abdominal
surgery. Which complication has occurred?
A) Hematoma
B) Seroma
C) Dehiscence
D) Granulation
