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EXAM OVERVIEW & TEST STRUCTURE
NR 224 Fundamentals of Nursing Exam 2 covers foundational nursing concepts
including:
- Skin Integrity and Wound Care
- Pain Management (Pharmacological and Nonpharmacological)
- Medication Administration (Rights, Routes, and Dosage Calculations)
- Nutrition and Hydration
- Bowel Elimination (Constipation, Diarrhea, Ostomies)
- Urinary Elimination (Catheters, Incontinence, UTIs)
- Oxygenation and Respiratory Support
- Fluid and Electrolyte Balance
- Complementary and Alternative Therapies
- Perioperative Nursing
SECTION 1: SKIN INTEGRITY & WOUND CARE (Questions 1–15)
QUESTION 1
A nurse is assessing a patient's pressure ulcer. The wound has full-thickness
tissue loss with visible adipose tissue and granulation tissue. There is no
exposed bone, tendon, or muscle. How should the nurse classify this pressure
ulcer?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
ANSWER: C) Stage 3
RATIONALE: A Stage 3 pressure ulcer has full-thickness tissue loss with visible
adipose (fat) tissue. Granulation tissue and rolled edges (epibole) may be
present. There is no exposed bone, tendon, or muscle. Stage 1 is
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,intact skin with non-blanchable erythema. Stage 2 involves partial-thickness
skin loss with exposed dermis. Stage 4 involves full-thickness tissue loss
with exposed bone, tendon, or muscle.
QUESTION 2
Which of the following is the most important nursing intervention for
preventing pressure ulcers in a bedridden patient?
A) Massage bony prominences daily
B) Reposition the patient at least every 2 hours
C) Use a donut-shaped ring cushion
D) Keep the patient in the supine position at all times
ANSWER: B) Reposition the patient at least every 2 hours
RATIONALE: Repositioning every 2 hours is the most effective intervention for
preventing pressure ulcers because it relieves pressure on bony prominences
and promotes blood flow. Massaging bony prominences can cause
tissue damage. Donut cushions can create pressure points and are not
recommended. Supine positioning alone is insufficient; position changes are
essential.
QUESTION 3
A nurse is caring for a patient with a surgical wound that is healing by
primary intention. Which statement best describes this type of wound healing?
A) The wound edges are approximated (closed) and heal with minimal scarring
B) The wound is left open and heals from the inside out
C) The wound heals by the formation of granulation tissue
D) The wound is intentionally left open to allow drainage
ANSWER: A) The wound edges are approximated (closed) and heal with minimal
scarring
RATIONALE: Primary intention healing occurs when wound edges are clean,
approximated (closed), and held together with sutures, staples, or adhesive.
Healing occurs quickly with minimal scarring. Secondary intention
involves wounds that are left open and heal from the inside out via
granulation tissue formation. Tertiary intention involves delayed closure.
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,QUESTION 4
What is the correct order for removing personal protective equipment (PPE)
after performing wound care?
A) Gloves → Gown → Mask → Eye protection → Hand hygiene
B) Gown → Gloves → Mask → Eye protection → Hand hygiene
C) Gloves → Eye protection → Gown → Mask → Hand hygiene
D) Mask → Gloves → Gown → Eye protection → Hand hygiene
ANSWER: C) Gloves → Eye protection → Gown → Mask → Hand hygiene
RATIONALE: The correct sequence for removing PPE is: remove gloves first
(most contaminated), then remove eye protection or goggles, then remove gown
(rolling it inward to contain contamination), then remove mask, and finally
perform hand hygiene. This sequence minimizes self-contamination.
QUESTION 5
A patient has a stage 2 pressure ulcer on the coccyx. Which wound dressing is
most appropriate for this wound?
A) Transparent film dressing
B) Hydrocolloid dressing
C) Alginate dressing
D) Wet-to-dry saline dressing
ANSWER: B) Hydrocolloid dressing
RATIONALE: Hydrocolloid dressings are appropriate for Stage 2 pressure ulcers
with partial-thickness tissue loss. They maintain a moist wound
environment, absorb light to moderate drainage, and are self-adhesive.
Transparent films are for superficial wounds with minimal drainage. Alginates
are for heavily draining wounds. Wet-to-dry dressings are used for mechanical
debridement, not for Stage 2 ulcers.
QUESTION 6
A nurse is performing wound irrigation. What is the correct pressure to use to
avoid damaging newly formed granulation tissue?
A) 1-2 psi
B) 4-6 psi
C) 8-10 psi
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, D) 12-15 psi
ANSWER: B) 4-6 psi
RATIONALE: The recommended pressure for wound irrigation is 4-15 psi, but
4-6 psi is the safe range that effectively cleans the wound without damaging
granulation tissue. Using a 35 mL syringe with a 19-gauge needle/catheter
generates about 8 psi. Pressures above 15 psi can drive bacteria into the
tissue and damage healthy cells.
QUESTION 7
Which of the following assessment findings indicates wound healing by
secondary intention?
A) The wound edges are well-approximated
B) Red, granular tissue fills the wound bed
C) The wound has a foul odor
D) The wound edges are pink and dry
ANSWER: B) Red, granular tissue fills the wound bed
RATIONALE: Secondary intention healing occurs when a wound is left open and
heals from the inside out. The formation of red, granular tissue (granulation
tissue) is a hallmark of this healing process. Well-approximated edges
indicate primary intention. Foul odor suggests infection, not healing.
QUESTION 8
A patient has a pressure ulcer with necrotic tissue (eschar) on the heel. What
is the priority nursing intervention?
A) Apply a moist dressing to soften the eschar
B) Debride the eschar to promote healing
C) Leave the eschar intact and monitor
D) Apply antibiotic ointment
ANSWER: C) Leave the eschar intact and monitor
RATIONALE: Dry, black eschar on a heel should be left intact and monitored
unless it becomes unstable, wet, or there are signs of infection. Eschar
provides a natural protective covering. Debridement is contraindicated on
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