NUR 205 Nursing Fundamentals Exam 7 - Galen College of Nursing
1. Which assessment finding is a characteristic sign of a Stage 2 pressure injury?
A. Full-thickness skin loss with visible adipose tissue
B. Non-blanchable erythema of intact skin
C. Full-thickness tissue loss with exposed bone or muscle
D. Partial-thickness skin loss with a exposed dermis
Answer: D
Rationale: A Stage 2 pressure injury involves partial-thickness loss of skin with exposed
dermis. It often presents as a shallow open ulcer with a red-pink wound bed or as an intact
or ruptured serum-filled blister.
2. The nurse is caring for a patient with a surgical wound that is healing by
primary intention. Which description best fits this process?
A. The wound is left open to heal from the bottom up
B. The wound is contaminated and requires delayed closure
C. The wound edges are approximated using sutures or staples
D. The wound heals through the formation of excessive granulation tissue
Answer: C
Rationale: Primary intention occurs when wound edges are pulled together
(approximated) and secured with sutures, staples, or adhesive, resulting in minimal
scarring.
,3. A patient’s wound drainage is thin, watery, and has a slightly pinkish color.
How should the nurse document this type of exudate?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
Answer: C
Rationale: Serosanguineous drainage is a mixture of serum and red blood cells, appearing
pale, pink, and watery.
4. Which score on the Braden Scale would indicate the highest risk for pressure
injury development?
A. 23
B. 18
C. 14
D. 9
Answer: D
Rationale: On the Braden Scale, lower scores indicate a higher risk for pressure injuries. A
score of 9 or less represents a very high risk.
5. When performing tracheostomy suctioning, what is the maximum amount of
time the nurse should apply suction?
A. 5 seconds
B. 1 minute
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and trauma
to the tracheal mucosa.
, 6. Which oxygen delivery device provides the most precise concentration of
oxygen?
A. Venturi mask
B. Simple face mask
C. Nasal cannula
D. Non-rebreather mask
Answer: A
Rationale: The Venturi mask is designed to deliver a specific, precise concentration of
oxygen regardless of the patient’s respiratory pattern.
7. A nurse observes a patient’s surgical wound and notes that the internal
organs are protruding through the incision. What is the priority nursing action?
A. Cover the organs with sterile towels moistened with sterile normal saline
B. Call the surgeon and prepare for emergency surgery
C. Apply a dry sterile dressing immediately
D. Push the organs back into the abdominal cavity
Answer: A
Rationale: Evisceration is a medical emergency. The nurse should cover the protruding
organs with sterile, saline-moistened dressings to prevent drying and infection, then notify
the surgeon.
8. What is the primary purpose of using an incentive spirometer
postoperatively?
A. To measure the patient’s forced expiratory volume
B. To provide supplemental oxygen to the alveoli
C. To promote deep breathing and prevent atelectasis
D. To decrease the patient’s heart rate during recovery
Answer: C
1. Which assessment finding is a characteristic sign of a Stage 2 pressure injury?
A. Full-thickness skin loss with visible adipose tissue
B. Non-blanchable erythema of intact skin
C. Full-thickness tissue loss with exposed bone or muscle
D. Partial-thickness skin loss with a exposed dermis
Answer: D
Rationale: A Stage 2 pressure injury involves partial-thickness loss of skin with exposed
dermis. It often presents as a shallow open ulcer with a red-pink wound bed or as an intact
or ruptured serum-filled blister.
2. The nurse is caring for a patient with a surgical wound that is healing by
primary intention. Which description best fits this process?
A. The wound is left open to heal from the bottom up
B. The wound is contaminated and requires delayed closure
C. The wound edges are approximated using sutures or staples
D. The wound heals through the formation of excessive granulation tissue
Answer: C
Rationale: Primary intention occurs when wound edges are pulled together
(approximated) and secured with sutures, staples, or adhesive, resulting in minimal
scarring.
,3. A patient’s wound drainage is thin, watery, and has a slightly pinkish color.
How should the nurse document this type of exudate?
A. Serous
B. Sanguineous
C. Serosanguineous
D. Purulent
Answer: C
Rationale: Serosanguineous drainage is a mixture of serum and red blood cells, appearing
pale, pink, and watery.
4. Which score on the Braden Scale would indicate the highest risk for pressure
injury development?
A. 23
B. 18
C. 14
D. 9
Answer: D
Rationale: On the Braden Scale, lower scores indicate a higher risk for pressure injuries. A
score of 9 or less represents a very high risk.
5. When performing tracheostomy suctioning, what is the maximum amount of
time the nurse should apply suction?
A. 5 seconds
B. 1 minute
C. 20 to 30 seconds
D. 10 to 15 seconds
Answer: D
Rationale: Suctioning should be limited to 10-15 seconds to prevent hypoxia and trauma
to the tracheal mucosa.
, 6. Which oxygen delivery device provides the most precise concentration of
oxygen?
A. Venturi mask
B. Simple face mask
C. Nasal cannula
D. Non-rebreather mask
Answer: A
Rationale: The Venturi mask is designed to deliver a specific, precise concentration of
oxygen regardless of the patient’s respiratory pattern.
7. A nurse observes a patient’s surgical wound and notes that the internal
organs are protruding through the incision. What is the priority nursing action?
A. Cover the organs with sterile towels moistened with sterile normal saline
B. Call the surgeon and prepare for emergency surgery
C. Apply a dry sterile dressing immediately
D. Push the organs back into the abdominal cavity
Answer: A
Rationale: Evisceration is a medical emergency. The nurse should cover the protruding
organs with sterile, saline-moistened dressings to prevent drying and infection, then notify
the surgeon.
8. What is the primary purpose of using an incentive spirometer
postoperatively?
A. To measure the patient’s forced expiratory volume
B. To provide supplemental oxygen to the alveoli
C. To promote deep breathing and prevent atelectasis
D. To decrease the patient’s heart rate during recovery
Answer: C
