Nursing 354 Pressure Injury Nursing
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. Which finding best describes a Stage 1 pressure injury?
A. Full-thickness skin loss with exposed adipose tissue
B. Partial-thickness skin loss with exposed dermis
C. Intact skin with non-blanchable erythema
D. Exposed muscle, tendon, or bone
Answer: C. Intact skin with non-blanchable erythema
Rationale: Stage 1 pressure injury presents as intact skin with localized non-
blanchable erythema. The area may also be painful, warmer or cooler, firmer or
softer than surrounding tissue.
2. Which patient has the greatest risk for developing a pressure injury?
A. A patient who ambulates independently
B. A patient with normal nutritional status
C. A patient who changes position frequently
D. An immobile patient with impaired sensation
Answer: D. An immobile patient with impaired sensation
,Rationale: Immobility and impaired sensation increase pressure-injury risk
because the patient may be unable to reposition or recognize discomfort from
prolonged pressure.
3. Which assessment tool is commonly used by nurses to evaluate pressure-injury
risk?
A. Glasgow Coma Scale
B. Morse Fall Scale
C. Braden Scale
D. Apgar Score
Answer: C. Braden Scale
Rationale: The Braden Scale evaluates factors such as sensory perception,
moisture, activity, mobility, nutrition, and friction/shear.
4. Which intervention is most appropriate for preventing pressure injuries in an
immobile patient?
A. Massage reddened areas
B. Keep the patient in one position
C. Reposition the patient according to an individualized schedule
D. Place a donut-shaped device beneath the sacrum
Answer: C. Reposition the patient according to an individualized schedule
Rationale: Regular repositioning reduces prolonged pressure and should be
individualized according to the patient's condition, mobility, tissue tolerance,
and support surface.
5. Which area is considered a common site for pressure injuries in a supine
patient?
,A. Abdomen
B. Sacrum
C. Forearm
D. Palm
Answer: B. Sacrum
Rationale: The sacrum is a prominent bony area exposed to pressure when a
patient remains supine for prolonged periods.
6. Which finding is characteristic of a Stage 2 pressure injury?
A. Exposed bone
B. Slough obscuring the wound bed
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness tissue loss with exposed muscle
Answer: C. Partial-thickness skin loss with exposed dermis
Rationale: Stage 2 involves partial-thickness skin loss with exposed dermis and
does not contain exposed adipose tissue, slough, or eschar.
7. A nurse observes full-thickness skin loss with visible adipose tissue but no
exposed fascia, muscle, tendon, cartilage, or bone. How should this injury be
classified?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C. Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss in which
adipose tissue may be visible, but deeper structures such as fascia, muscle,
tendon, cartilage, and bone are not exposed.
, 8. Which finding indicates a Stage 4 pressure injury?
A. Intact skin with persistent redness
B. Partial-thickness skin loss
C. Exposed dermis only
D. Exposed or directly palpable fascia, muscle, tendon, cartilage, or bone
Answer: D. Exposed or directly palpable fascia, muscle, tendon, cartilage, or
bone
Rationale: Stage 4 is full-thickness skin and tissue loss with exposed or directly
palpable deeper anatomical structures.
9. Which patient position generally places the least pressure on the sacrum?
A. Supine
B. High-Fowler's
C. Side-lying with appropriate positioning support
D. Sitting upright
Answer: C. Side-lying with appropriate positioning support
Rationale: Proper side-lying positioning can offload the sacrum and other
pressure-prone areas while distributing body weight across a larger surface.
10. Which action should the nurse take when repositioning a dependent patient?
A. Drag the patient across the bed
B. Pull directly on the patient's arms
C. Use a lift device or draw sheet to reduce friction and shear
D. Ask the patient to hold onto the bedrail while being pulled
Answer: C. Use a lift device or draw sheet to reduce friction and shear
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. Which finding best describes a Stage 1 pressure injury?
A. Full-thickness skin loss with exposed adipose tissue
B. Partial-thickness skin loss with exposed dermis
C. Intact skin with non-blanchable erythema
D. Exposed muscle, tendon, or bone
Answer: C. Intact skin with non-blanchable erythema
Rationale: Stage 1 pressure injury presents as intact skin with localized non-
blanchable erythema. The area may also be painful, warmer or cooler, firmer or
softer than surrounding tissue.
2. Which patient has the greatest risk for developing a pressure injury?
A. A patient who ambulates independently
B. A patient with normal nutritional status
C. A patient who changes position frequently
D. An immobile patient with impaired sensation
Answer: D. An immobile patient with impaired sensation
,Rationale: Immobility and impaired sensation increase pressure-injury risk
because the patient may be unable to reposition or recognize discomfort from
prolonged pressure.
3. Which assessment tool is commonly used by nurses to evaluate pressure-injury
risk?
A. Glasgow Coma Scale
B. Morse Fall Scale
C. Braden Scale
D. Apgar Score
Answer: C. Braden Scale
Rationale: The Braden Scale evaluates factors such as sensory perception,
moisture, activity, mobility, nutrition, and friction/shear.
4. Which intervention is most appropriate for preventing pressure injuries in an
immobile patient?
A. Massage reddened areas
B. Keep the patient in one position
C. Reposition the patient according to an individualized schedule
D. Place a donut-shaped device beneath the sacrum
Answer: C. Reposition the patient according to an individualized schedule
Rationale: Regular repositioning reduces prolonged pressure and should be
individualized according to the patient's condition, mobility, tissue tolerance,
and support surface.
5. Which area is considered a common site for pressure injuries in a supine
patient?
,A. Abdomen
B. Sacrum
C. Forearm
D. Palm
Answer: B. Sacrum
Rationale: The sacrum is a prominent bony area exposed to pressure when a
patient remains supine for prolonged periods.
6. Which finding is characteristic of a Stage 2 pressure injury?
A. Exposed bone
B. Slough obscuring the wound bed
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness tissue loss with exposed muscle
Answer: C. Partial-thickness skin loss with exposed dermis
Rationale: Stage 2 involves partial-thickness skin loss with exposed dermis and
does not contain exposed adipose tissue, slough, or eschar.
7. A nurse observes full-thickness skin loss with visible adipose tissue but no
exposed fascia, muscle, tendon, cartilage, or bone. How should this injury be
classified?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Answer: C. Stage 3
Rationale: Stage 3 pressure injury involves full-thickness skin loss in which
adipose tissue may be visible, but deeper structures such as fascia, muscle,
tendon, cartilage, and bone are not exposed.
, 8. Which finding indicates a Stage 4 pressure injury?
A. Intact skin with persistent redness
B. Partial-thickness skin loss
C. Exposed dermis only
D. Exposed or directly palpable fascia, muscle, tendon, cartilage, or bone
Answer: D. Exposed or directly palpable fascia, muscle, tendon, cartilage, or
bone
Rationale: Stage 4 is full-thickness skin and tissue loss with exposed or directly
palpable deeper anatomical structures.
9. Which patient position generally places the least pressure on the sacrum?
A. Supine
B. High-Fowler's
C. Side-lying with appropriate positioning support
D. Sitting upright
Answer: C. Side-lying with appropriate positioning support
Rationale: Proper side-lying positioning can offload the sacrum and other
pressure-prone areas while distributing body weight across a larger surface.
10. Which action should the nurse take when repositioning a dependent patient?
A. Drag the patient across the bed
B. Pull directly on the patient's arms
C. Use a lift device or draw sheet to reduce friction and shear
D. Ask the patient to hold onto the bedrail while being pulled
Answer: C. Use a lift device or draw sheet to reduce friction and shear
