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NUR 155 – FOUNDATIONS OF NURSING Exam 3 Review Guide Version
2 | Latest Fall 2026 Questions with Detailed Rationales
Question 1
A nurse is caring for a client with a wound that has a large
amount of necrotic tissue and eschar. Which type of
debridement is most appropriate for rapid removal?
A. Autolytic
B. Enzymatic
C. Sharp or surgical
D. Mechanical only
Answer: C
Rationale: Sharp/surgical debridement is the fastest method to
remove necrotic tissue and eschar. Autolytic and enzymatic are
slower; mechanical may be painful and less selective.
Question 2
Which of the following clients is at highest risk for a pressure
injury?
A. A 45-year-old who ambulates three times daily
B. A 70-year-old with hip fracture, incontinence, and poor
intake
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C. A 30-year-old with a broken arm
D. A 50-year-old with normal mobility
Answer: B
Rationale: Immobility, incontinence, poor nutrition, and
advanced age are major risk factors for pressure injury
development.
Question 3
A nurse is assessing a wound and notes a shallow, open area
with a red-pink wound bed and no slough. What stage of
pressure injury is this?
A. Stage 1
B. Stage 2
C. Stage 3
D. Unstageable
Answer: B
Rationale: Stage 2 is partial-thickness skin loss with a red-pink
wound bed, without slough. Stage 1 is intact skin with non-
blanchable erythema.
Question 4
Which of the following is a sign of wound infection?
A. Granulation tissue
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B. Purulent drainage, erythema, warmth, and fever
C. Serosanguineous drainage
D. No pain
Answer: B
Rationale: Purulent drainage, spreading erythema, warmth,
edema, and fever indicate infection. Granulation and
serosanguineous drainage are normal healing.
Question 5
A client with a stage 3 pressure injury has full-thickness skin loss
with visible subcutaneous fat. Which layer is NOT involved?
A. Epidermis
B. Dermis
C. Subcutaneous tissue
D. Muscle and bone
Answer: D
Rationale: Stage 3 involves full-thickness skin loss with
subcutaneous fat visible; muscle and bone are not exposed.
Stage 4 involves muscle/bone.
Question 6
Which of the following is the best intervention to prevent shear
injury in a bedridden client?
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A. Keep the head of bed elevated 90 degrees
B. Use a lift sheet and keep the head of bed at 30 degrees or
less
C. Pull the client up in bed without lifting
D. Massage reddened areas
Answer: B
Rationale: Shear occurs when skin and underlying tissue move
in opposite directions. Using a lift sheet and limiting HOB
elevation reduce shear.
Question 7
A nurse is caring for a client with a wound that is healing by
secondary intention. Which finding is expected?
A. Edges approximated with minimal granulation
B. Large wound gap filled with granulation tissue and eventual
scar
C. No inflammation
D. Primary closure with sutures
Answer: B
Rationale: Secondary intention heals by granulation,
contraction, and epithelialization because wound edges are not
approximated, leaving a larger scar.
NUR 155 – FOUNDATIONS OF NURSING Exam 3 Review Guide Version
2 | Latest Fall 2026 Questions with Detailed Rationales
Question 1
A nurse is caring for a client with a wound that has a large
amount of necrotic tissue and eschar. Which type of
debridement is most appropriate for rapid removal?
A. Autolytic
B. Enzymatic
C. Sharp or surgical
D. Mechanical only
Answer: C
Rationale: Sharp/surgical debridement is the fastest method to
remove necrotic tissue and eschar. Autolytic and enzymatic are
slower; mechanical may be painful and less selective.
Question 2
Which of the following clients is at highest risk for a pressure
injury?
A. A 45-year-old who ambulates three times daily
B. A 70-year-old with hip fracture, incontinence, and poor
intake
, Page |2
C. A 30-year-old with a broken arm
D. A 50-year-old with normal mobility
Answer: B
Rationale: Immobility, incontinence, poor nutrition, and
advanced age are major risk factors for pressure injury
development.
Question 3
A nurse is assessing a wound and notes a shallow, open area
with a red-pink wound bed and no slough. What stage of
pressure injury is this?
A. Stage 1
B. Stage 2
C. Stage 3
D. Unstageable
Answer: B
Rationale: Stage 2 is partial-thickness skin loss with a red-pink
wound bed, without slough. Stage 1 is intact skin with non-
blanchable erythema.
Question 4
Which of the following is a sign of wound infection?
A. Granulation tissue
, Page |3
B. Purulent drainage, erythema, warmth, and fever
C. Serosanguineous drainage
D. No pain
Answer: B
Rationale: Purulent drainage, spreading erythema, warmth,
edema, and fever indicate infection. Granulation and
serosanguineous drainage are normal healing.
Question 5
A client with a stage 3 pressure injury has full-thickness skin loss
with visible subcutaneous fat. Which layer is NOT involved?
A. Epidermis
B. Dermis
C. Subcutaneous tissue
D. Muscle and bone
Answer: D
Rationale: Stage 3 involves full-thickness skin loss with
subcutaneous fat visible; muscle and bone are not exposed.
Stage 4 involves muscle/bone.
Question 6
Which of the following is the best intervention to prevent shear
injury in a bedridden client?
, Page |4
A. Keep the head of bed elevated 90 degrees
B. Use a lift sheet and keep the head of bed at 30 degrees or
less
C. Pull the client up in bed without lifting
D. Massage reddened areas
Answer: B
Rationale: Shear occurs when skin and underlying tissue move
in opposite directions. Using a lift sheet and limiting HOB
elevation reduce shear.
Question 7
A nurse is caring for a client with a wound that is healing by
secondary intention. Which finding is expected?
A. Edges approximated with minimal granulation
B. Large wound gap filled with granulation tissue and eventual
scar
C. No inflammation
D. Primary closure with sutures
Answer: B
Rationale: Secondary intention heals by granulation,
contraction, and epithelialization because wound edges are not
approximated, leaving a larger scar.
