NUR 316 Test Bank Exam 2 | Verified set | Spring 2026
| Questions and Answers
1. The nurse is working on a medical-surgical unit that has been participating in a research
project associated with pressure ulcers. Which risk factor will the nurse assess for that
predisposes a patient to pressure ulcer development? - ANSWER-Decreased level of
consciousness
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. Which priority element will the nurse
consider when planning care to decrease the development of a decubitus ulcer? - ANSWER-
Pressure
3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation? -
ANSWER-The patient has fecal incontinence.
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 should the nurse document this ulcer in the patient's medical record? -
ANSWER-Healing Stage III pressure ulcer
. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse
notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How
will the nurse stage this pressure ulcer? - ANSWER-Stage II
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which
item should the nurse use first to assist in staging an ulcer on this patient? - ANSWER-d. Halogen
light
7. The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the
nurse consider when planning care for this patient? - ANSWER-Full-thickness wound repair
8. The nurse is caring for a group of patients. Which patient will the nurse see first - ANSWER-A
patient with appendicitis using a heating pad
9. The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of
tissue will the nurse expect to observe when the wound is healing? - ANSWER-Granulation
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For
which type of healing will the nurse focus the care plan? - ANSWER-Primary intention
, The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse
consider when planning care for this patient? - ANSWER-Secondary intention
12. A nurse is assessing a patient's wound. Which nursing observation will indicate the wound
healed by secondary intention - ANSWER-Scarring that may be severe
13. The nurse is caring for a patient who has experienced a total abdominal hysterectomy.
Which nursing observation of the incision will indicate the patient is experiencing a complication
of wound healing? - ANSWER-The site has a mass, bluish in color.
14. A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential
wound dehiscence? - ANSWER-Report by patient that something has given way
15. A patient has developed a pressure ulcer. Which laboratory data will be important for the
nurse to check? - ANSWER-Albumin
16. A nurse is caring for a patient with a wound. Which assessment data will be most important
for the nurse to gather with regard to wound healing? - ANSWER-Pulse oximetry assessment
17. The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the
room, the nurse notices an odor and observes a purulent discharge, along with increased
redness at the wound site. What is the next best step for the nurse? - ANSWER-Complete the
head-to-toe assessment, including current treatment, vital signs, and laboratory results.
18. The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer.
Which nutrient will the nurse most likely increase after collaboration with the dietitian? -
ANSWER-Protein
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The
wound is odorous, and a drain is currently in place. Which statement by the patient indicates
issues with self-concept? - ANSWER-"I am ready for my bath and linen change right now since
this is awful."
20. A patient presents to the emergency department with a laceration of the right forearm
caused by a fall. After determining that the patient is stable, what is the next best step for the
nurse to take? - ANSWER-Inspect the wound for bleeding.
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and
a dressing that needs changing. Which action should the nurse take first? - ANSWER-Provide
analgesic medications as ordered.
The nurse is caring for a patient who has a wound drain with a collection device. The nurse
notices that the collection device has a sudden decrease in drainage. Which action will the
nurse take next? - ANSWER-Call the health care provider; a blockage is present in the tubing.
| Questions and Answers
1. The nurse is working on a medical-surgical unit that has been participating in a research
project associated with pressure ulcers. Which risk factor will the nurse assess for that
predisposes a patient to pressure ulcer development? - ANSWER-Decreased level of
consciousness
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. Which priority element will the nurse
consider when planning care to decrease the development of a decubitus ulcer? - ANSWER-
Pressure
3. Which nursing observation will indicate the patient is at risk for pressure ulcer formation? -
ANSWER-The patient has fecal incontinence.
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 should the nurse document this ulcer in the patient's medical record? -
ANSWER-Healing Stage III pressure ulcer
. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse
notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How
will the nurse stage this pressure ulcer? - ANSWER-Stage II
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which
item should the nurse use first to assist in staging an ulcer on this patient? - ANSWER-d. Halogen
light
7. The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the
nurse consider when planning care for this patient? - ANSWER-Full-thickness wound repair
8. The nurse is caring for a group of patients. Which patient will the nurse see first - ANSWER-A
patient with appendicitis using a heating pad
9. The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of
tissue will the nurse expect to observe when the wound is healing? - ANSWER-Granulation
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For
which type of healing will the nurse focus the care plan? - ANSWER-Primary intention
, The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse
consider when planning care for this patient? - ANSWER-Secondary intention
12. A nurse is assessing a patient's wound. Which nursing observation will indicate the wound
healed by secondary intention - ANSWER-Scarring that may be severe
13. The nurse is caring for a patient who has experienced a total abdominal hysterectomy.
Which nursing observation of the incision will indicate the patient is experiencing a complication
of wound healing? - ANSWER-The site has a mass, bluish in color.
14. A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential
wound dehiscence? - ANSWER-Report by patient that something has given way
15. A patient has developed a pressure ulcer. Which laboratory data will be important for the
nurse to check? - ANSWER-Albumin
16. A nurse is caring for a patient with a wound. Which assessment data will be most important
for the nurse to gather with regard to wound healing? - ANSWER-Pulse oximetry assessment
17. The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the
room, the nurse notices an odor and observes a purulent discharge, along with increased
redness at the wound site. What is the next best step for the nurse? - ANSWER-Complete the
head-to-toe assessment, including current treatment, vital signs, and laboratory results.
18. The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer.
Which nutrient will the nurse most likely increase after collaboration with the dietitian? -
ANSWER-Protein
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The
wound is odorous, and a drain is currently in place. Which statement by the patient indicates
issues with self-concept? - ANSWER-"I am ready for my bath and linen change right now since
this is awful."
20. A patient presents to the emergency department with a laceration of the right forearm
caused by a fall. After determining that the patient is stable, what is the next best step for the
nurse to take? - ANSWER-Inspect the wound for bleeding.
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and
a dressing that needs changing. Which action should the nurse take first? - ANSWER-Provide
analgesic medications as ordered.
The nurse is caring for a patient who has a wound drain with a collection device. The nurse
notices that the collection device has a sudden decrease in drainage. Which action will the
nurse take next? - ANSWER-Call the health care provider; a blockage is present in the tubing.
