BSN 206 Quiz 5 Hygiene, Skin Integrity, and Wound Care
Management (Module 5 with 50 questions and correct answers)
Covers the prevention of pressure injuries, wound healing phases, dressing
selection, and advanced skin assessments.
1. Which staging classification applies to a localized area of intact skin with
non-blanchable erythema?
* A) Stage 1 Pressure Injury
* B) Stage 2 Pressure Injury
* C) Stage 3 Pressure Injury
* D) Unstageable Pressure Injury
* Rationale: A Stage 1 pressure injury features intact skin with a localized
area of non-blanchable erythema (redness that does not turn white when
pressed), often over a bony prominence.
1. A nurse notes a pressure injury with partial-thickness loss of skin
exposing the dermis. The wound bed is viable, pink, and moist. How is this
classified?
* A) Stage 1 Pressure Injury
* B) Stage 2 Pressure Injury
* C) Stage 3 Pressure Injury
* D) Deep Tissue Pressure Injury
* Rationale: Stage 2 pressure injuries present with partial-thickness skin loss
involving the epidermis and dermis, visible as a shallow open ulcer or an
intact/ruptured serum-filled blister.
, 1. A deep wound reveals full-thickness skin loss with visible subcutaneous
fat and granulation tissue. Bone, tendon, and muscle are not exposed. This is
a:
* A) Stage 2 Pressure Injury
* B) Stage 3 Pressure Injury
* C) Stage 4 Pressure Injury
* D) Unstageable Pressure Injury
* Rationale: Stage 3 involves full-thickness tissue loss where adipose (fat)
tissue is visible in the ulcer, but deeper structures like bone, tendon, or
muscle are not exposed.
1. A nurse assesses a sacral ulcer displaying full-thickness skin and tissue
loss with directly palpable bone and fascia. This wound is classified as:
* A) Stage 3 Pressure Injury
* B) Stage 4 Pressure Injury
* C) Unstageable Pressure Injury
* D) Deep Tissue Pressure Injury
* Rationale: Stage 4 is characterized by full-thickness skin and tissue loss
with exposed or directly palpable bone, tendon, ligament, cartilage, or
muscle.
, 1. Why would a pressure injury be classified as "Unstageable"?
* A) Because it is located on an area with poor circulation
* B) Because the true depth of tissue damage is obscured by slough or
eschar
* C) Because it was acquired in a home setting rather than a hospital
* D) Because the wound is too small to measure accurately
* Rationale: If slough (yellow, tan, gray, or green devitalized tissue) or eschar
(tan, brown, or black necrotic tissue) covers the wound bed, the nurse cannot
visualize the base to determine the true depth, rendering it unstageable until
debrided.
1. A nurse notes a persistent, non-blanchable deep red or purple
discoloration of intact skin over a patient's heel. This finding represents a:
* A) Stage 1 Pressure Injury
* B) Stage 2 Pressure Injury
* C) Deep Tissue Pressure Injury (DTPI)
* D) Stage 4 Pressure Injury
* Rationale: Deep Tissue Pressure Injuries present as intact or non-intact skin
with localized, persistent non-blanchable deep red, maroon, or purple
discoloration, or epidermal separation revealing a dark wound bed, indicating
deep underlying structural damage.
1. Which risk assessment scale is most widely utilized in clinical practice to
evaluate a patient's risk for skin breakdown?
Management (Module 5 with 50 questions and correct answers)
Covers the prevention of pressure injuries, wound healing phases, dressing
selection, and advanced skin assessments.
1. Which staging classification applies to a localized area of intact skin with
non-blanchable erythema?
* A) Stage 1 Pressure Injury
* B) Stage 2 Pressure Injury
* C) Stage 3 Pressure Injury
* D) Unstageable Pressure Injury
* Rationale: A Stage 1 pressure injury features intact skin with a localized
area of non-blanchable erythema (redness that does not turn white when
pressed), often over a bony prominence.
1. A nurse notes a pressure injury with partial-thickness loss of skin
exposing the dermis. The wound bed is viable, pink, and moist. How is this
classified?
* A) Stage 1 Pressure Injury
* B) Stage 2 Pressure Injury
* C) Stage 3 Pressure Injury
* D) Deep Tissue Pressure Injury
* Rationale: Stage 2 pressure injuries present with partial-thickness skin loss
involving the epidermis and dermis, visible as a shallow open ulcer or an
intact/ruptured serum-filled blister.
, 1. A deep wound reveals full-thickness skin loss with visible subcutaneous
fat and granulation tissue. Bone, tendon, and muscle are not exposed. This is
a:
* A) Stage 2 Pressure Injury
* B) Stage 3 Pressure Injury
* C) Stage 4 Pressure Injury
* D) Unstageable Pressure Injury
* Rationale: Stage 3 involves full-thickness tissue loss where adipose (fat)
tissue is visible in the ulcer, but deeper structures like bone, tendon, or
muscle are not exposed.
1. A nurse assesses a sacral ulcer displaying full-thickness skin and tissue
loss with directly palpable bone and fascia. This wound is classified as:
* A) Stage 3 Pressure Injury
* B) Stage 4 Pressure Injury
* C) Unstageable Pressure Injury
* D) Deep Tissue Pressure Injury
* Rationale: Stage 4 is characterized by full-thickness skin and tissue loss
with exposed or directly palpable bone, tendon, ligament, cartilage, or
muscle.
, 1. Why would a pressure injury be classified as "Unstageable"?
* A) Because it is located on an area with poor circulation
* B) Because the true depth of tissue damage is obscured by slough or
eschar
* C) Because it was acquired in a home setting rather than a hospital
* D) Because the wound is too small to measure accurately
* Rationale: If slough (yellow, tan, gray, or green devitalized tissue) or eschar
(tan, brown, or black necrotic tissue) covers the wound bed, the nurse cannot
visualize the base to determine the true depth, rendering it unstageable until
debrided.
1. A nurse notes a persistent, non-blanchable deep red or purple
discoloration of intact skin over a patient's heel. This finding represents a:
* A) Stage 1 Pressure Injury
* B) Stage 2 Pressure Injury
* C) Deep Tissue Pressure Injury (DTPI)
* D) Stage 4 Pressure Injury
* Rationale: Deep Tissue Pressure Injuries present as intact or non-intact skin
with localized, persistent non-blanchable deep red, maroon, or purple
discoloration, or epidermal separation revealing a dark wound bed, indicating
deep underlying structural damage.
1. Which risk assessment scale is most widely utilized in clinical practice to
evaluate a patient's risk for skin breakdown?
