NSG 300 EXAM 2 | COMPREHENSIVE NURSING STUDY GUIDE, PRACTICE
QUESTIONS & ANSWERS 2026/2027
What are 3 pressure related factors that contribute to pressure ulcer development? - correct answer
✔✔1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - correct answer ✔✔If pressure applied over a capillary
exceeds normal capillary pressure and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - correct answer ✔✔tissue death
Does blanching occur in dark skinned patients? - correct answer ✔✔No, blanching does not occur but
color, texture and temp may differ from surrounding area
What does pressure duration assess? - correct answer ✔✔Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - correct answer ✔✔the ability of tissue to endure pressure which is
dependent on the integrity of the tissue and supporting structures
What are risk factors of pressure injuries? - correct answer ✔✔◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - correct answer ✔✔Wound location,
staging, type and approximate percentage of tissue in wound bed, wound dimensions (sinus tracts and
tunneling), exudate description and condition of surrounding skin
stage 1 pressure injury - correct answer ✔✔Intact skin with nonblanchable redness
stage 2 pressure injury - correct answer ✔✔partial thickness skin loss involving epidermis, dermis or
both and, shallow abrasion or open blister looking
stage 3 pressure injury - correct answer ✔✔full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury - correct answer ✔✔full thickness with exposed bone, muscle or tendon and may
have eschar
What characteristics does stage 3 and 4 pressure injuries share? - correct answer ✔✔They may have
slough, undermining and tunneling present
,A nurse states slough is present in a stage 3 pressure injury. What should the student nurse expect to
see? - correct answer ✔✔A yellow or white, stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the student nurse expect to
see? - correct answer ✔✔brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - correct answer ✔✔Tissue loss but depth unknown because
wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its own".
What education should the nurse provide? - correct answer ✔✔Slough and eschar must be removed by
a clinician to determine the stage and in order for healing to occur
suspected deep tissue injury - correct 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. Depth
unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What should the student
nurse expect to see? - correct answer ✔✔Red, moist tissue which indicates progression toward healing
What should the nurse document when assessing exudate? - correct answer ✔✔Amount, color,
consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does this indicate? -
correct answer ✔✔The presence of infection
What should the nurse look for when assessing the periwound area? Why is it important? - correct
answer ✔✔Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - correct answer ✔✔Allows a nurse to understand the risks
associated with a wound and implications for healing
How does a partial thickness wound heal? - correct answer ✔✔Heals by regeneration
How does a full thickness would heal? - correct answer ✔✔Heals by forming new tissue which takes
longer
What are the three components involved in the healing process of a partial thickness wound? - correct
answer ✔✔Inflammatory response, epithelial proliferation and migration, and reestablishment of
epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal quickly. What education
should the nurse provide to the patient? - correct answer ✔✔Wounds heal faster in moist environments
because epidermal cells only migrate across moist surfaces.
, Reestablishment of the epidermal layers - correct answer ✔✔New epithelium is only a few cells thick.
Cells slowly reestablish normal thickness and appear as dry, pink tissue
What are the four stages involved in the healing process of a full thickness wound? - correct answer
✔✔Hemostasis, inflammation, proliferation and maturation
Primary intention healing - correct answer ✔✔The skin edges are approximated, or closed, and the risk
of infection is low. Healing occurs quickly, with minimal scar formation, as long as infection and
secondary breakdown are prevented
Secondary infection healing - correct answer ✔✔Wound is left open until it becomes filed by scar tissue.
It takes longer for a wound to heal by secondary intention increasing the chance of infection
hemorrhage - correct answer ✔✔bleeding from a wound site is normal during and immediately after
initial trauma
A nurse suspects internal bleeding. How would the nurses assess the patient to confirm her findings? -
correct answer ✔✔By assessing for distention or swelling of the affected body part, change in type and
amount of drainage from a surgical drain r signs of hypovolemic shock
Hematoma - correct answer ✔✔localized collection of blood underneath the tissue
dihiscence - correct answer ✔✔partial or total separation of wound layers
Evisceration - correct answer ✔✔protrusion of visceral organs through a wound opening
What is the second most common health care associated infection? - correct answer ✔✔wound
infection
What are the signs and symptoms of wound infection? - correct answer ✔✔Fever, tenderness and pain
at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
A student nurse is asked to perform a risk assessment of pressure ulcers on patient. How should the
nurse determine the patient's risk? - correct answer ✔✔Using the Braden scale. Lower numbers
indicates the patient is at a high risk for skin breakdown.
What are the 6 components of the Braden Scale? - correct answer ✔✔sensory perception, moisture,
activity, mobility, nutrition, friction/shear
what did the Centers of Medicare and Medicaid Services (CMS) implement to help improve quality of
care in regards to pressure ulcers? - correct answer ✔✔Hospitals no longer receive additional
reimbursement for care related to stage 3 and 4 pressure ulcers that occur during hospitalizations
Why is important for the admitting nurse to observe ALL areas of skin? - correct answer ✔✔Due to the
CMS implements. So if the nurse misses an ulcer, the hospital will not be paid for the cost to care for it.
QUESTIONS & ANSWERS 2026/2027
What are 3 pressure related factors that contribute to pressure ulcer development? - correct answer
✔✔1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - correct answer ✔✔If pressure applied over a capillary
exceeds normal capillary pressure and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - correct answer ✔✔tissue death
Does blanching occur in dark skinned patients? - correct answer ✔✔No, blanching does not occur but
color, texture and temp may differ from surrounding area
What does pressure duration assess? - correct answer ✔✔Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? - correct answer ✔✔the ability of tissue to endure pressure which is
dependent on the integrity of the tissue and supporting structures
What are risk factors of pressure injuries? - correct answer ✔✔◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
What should the nurse look for when assessing a pressure injury? - correct answer ✔✔Wound location,
staging, type and approximate percentage of tissue in wound bed, wound dimensions (sinus tracts and
tunneling), exudate description and condition of surrounding skin
stage 1 pressure injury - correct answer ✔✔Intact skin with nonblanchable redness
stage 2 pressure injury - correct answer ✔✔partial thickness skin loss involving epidermis, dermis or
both and, shallow abrasion or open blister looking
stage 3 pressure injury - correct answer ✔✔full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury - correct answer ✔✔full thickness with exposed bone, muscle or tendon and may
have eschar
What characteristics does stage 3 and 4 pressure injuries share? - correct answer ✔✔They may have
slough, undermining and tunneling present
,A nurse states slough is present in a stage 3 pressure injury. What should the student nurse expect to
see? - correct answer ✔✔A yellow or white, stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What should the student nurse expect to
see? - correct answer ✔✔brown or black necrotic tissue
Unstageable/Unclassified Pressure Ulcer - correct answer ✔✔Tissue loss but depth unknown because
wound bed is obscured by slough and/or eschar
A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its own".
What education should the nurse provide? - correct answer ✔✔Slough and eschar must be removed by
a clinician to determine the stage and in order for healing to occur
suspected deep tissue injury - correct 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. Depth
unknown
A nurse is assessing a wound and notes the presence of granulation tissue. What should the student
nurse expect to see? - correct answer ✔✔Red, moist tissue which indicates progression toward healing
What should the nurse document when assessing exudate? - correct answer ✔✔Amount, color,
consistency and odor
The student nurse sees an excess amount of exudate in the wound bed. What does this indicate? -
correct answer ✔✔The presence of infection
What should the nurse look for when assessing the periwound area? Why is it important? - correct
answer ✔✔Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
Why is wound classification important? - correct answer ✔✔Allows a nurse to understand the risks
associated with a wound and implications for healing
How does a partial thickness wound heal? - correct answer ✔✔Heals by regeneration
How does a full thickness would heal? - correct answer ✔✔Heals by forming new tissue which takes
longer
What are the three components involved in the healing process of a partial thickness wound? - correct
answer ✔✔Inflammatory response, epithelial proliferation and migration, and reestablishment of
epidermal layers
A patient states keeping his wound exposed to air while allow his wound to heal quickly. What education
should the nurse provide to the patient? - correct answer ✔✔Wounds heal faster in moist environments
because epidermal cells only migrate across moist surfaces.
, Reestablishment of the epidermal layers - correct answer ✔✔New epithelium is only a few cells thick.
Cells slowly reestablish normal thickness and appear as dry, pink tissue
What are the four stages involved in the healing process of a full thickness wound? - correct answer
✔✔Hemostasis, inflammation, proliferation and maturation
Primary intention healing - correct answer ✔✔The skin edges are approximated, or closed, and the risk
of infection is low. Healing occurs quickly, with minimal scar formation, as long as infection and
secondary breakdown are prevented
Secondary infection healing - correct answer ✔✔Wound is left open until it becomes filed by scar tissue.
It takes longer for a wound to heal by secondary intention increasing the chance of infection
hemorrhage - correct answer ✔✔bleeding from a wound site is normal during and immediately after
initial trauma
A nurse suspects internal bleeding. How would the nurses assess the patient to confirm her findings? -
correct answer ✔✔By assessing for distention or swelling of the affected body part, change in type and
amount of drainage from a surgical drain r signs of hypovolemic shock
Hematoma - correct answer ✔✔localized collection of blood underneath the tissue
dihiscence - correct answer ✔✔partial or total separation of wound layers
Evisceration - correct answer ✔✔protrusion of visceral organs through a wound opening
What is the second most common health care associated infection? - correct answer ✔✔wound
infection
What are the signs and symptoms of wound infection? - correct answer ✔✔Fever, tenderness and pain
at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
A student nurse is asked to perform a risk assessment of pressure ulcers on patient. How should the
nurse determine the patient's risk? - correct answer ✔✔Using the Braden scale. Lower numbers
indicates the patient is at a high risk for skin breakdown.
What are the 6 components of the Braden Scale? - correct answer ✔✔sensory perception, moisture,
activity, mobility, nutrition, friction/shear
what did the Centers of Medicare and Medicaid Services (CMS) implement to help improve quality of
care in regards to pressure ulcers? - correct answer ✔✔Hospitals no longer receive additional
reimbursement for care related to stage 3 and 4 pressure ulcers that occur during hospitalizations
Why is important for the admitting nurse to observe ALL areas of skin? - correct answer ✔✔Due to the
CMS implements. So if the nurse misses an ulcer, the hospital will not be paid for the cost to care for it.
