Question 1: A nurse is assessing a client's skin integrity. Which finding is most
characteristic of a Stage I pressure ulcer?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: A. Intact skin with nonblanchable redness
Rationale: A Stage I pressure ulcer presents as intact skin with nonblanchable redness
over a bony prominence. Early recognition and pressure relief prevent progression to
more advanced stages.
Question 2: A nurse is assessing a client with a Stage II pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: B. Partial-thickness skin loss with a shallow open ulcer
Rationale: A Stage II pressure ulcer involves partial-thickness loss of the dermis,
presenting as a shallow open ulcer with a red-pink wound bed or a blister. It requires
moist wound healing and pressure relief.
Question 3: A nurse is assessing a client with a Stage III pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: C. Full-thickness tissue loss with visible subcutaneous fat
Rationale: A Stage III pressure ulcer involves full-thickness tissue loss with visible
subcutaneous fat but no exposed bone, tendon, or muscle. Slough may be present but
does not obscure the depth of tissue loss.
Question 4: A nurse is assessing a client with a Stage IV pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
,C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: D. Full-thickness loss with exposed bone, tendon, or muscle
Rationale: A Stage IV pressure ulcer involves full-thickness tissue loss with exposed
bone, tendon, or muscle. It requires aggressive wound care and may necessitate
surgical intervention.
Question 5: A nurse is assessing a client with an unstageable pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss
C. Full-thickness tissue loss obscured by slough or eschar
D. Full-thickness loss with exposed bone
CORRECT ANSWER: C. Full-thickness tissue loss obscured by slough or eschar
Rationale: An unstageable pressure ulcer involves full-thickness tissue loss obscured
by slough or eschar. The wound cannot be staged until the slough or eschar is removed.
Question 6: A nurse is assessing a client with a deep tissue injury. Which finding is
expected?
A. Intact skin with nonblanchable redness
B. Purple or maroon localized area of discolored intact skin
C. Full-thickness tissue loss
D. Exposed bone, tendon, or muscle
CORRECT ANSWER: B. Purple or maroon localized area of discolored intact skin
Rationale: A deep tissue injury presents as a purple or maroon localized area of
discolored intact skin or a blood-filled blister. It may evolve into a full-thickness ulcer.
Question 7: A nurse is caring for a client at risk for pressure ulcers. Which
intervention is priority?
A. Reposition the client every 2 hours
B. Keep the client in one position
C. Restrict all fluids
D. Massage reddened areas
CORRECT ANSWER: A. Reposition the client every 2 hours
Rationale: Repositioning every 2 hours relieves pressure over bony prominences and
prevents pressure ulcer development. Massaging reddened areas can cause further
tissue damage.
,Question 8: A nurse is using the Braden Scale to assess a client's risk for pressure
ulcers. Which score indicates the highest risk?
A. Score of 23
B. Score of 18
C. Score of 12
D. Score of 6
CORRECT ANSWER: D. Score of 6
Rationale: The Braden Scale ranges from 6 to 23, with lower scores indicating higher
risk. A score of 6 indicates severe risk for pressure ulcer development.
Question 9: A nurse is assessing a client with a suspected arterial ulcer. Which
finding is most characteristic?
A. Severe pain, pale skin, and decreased pulses
B. Edema, warm skin, and ulcers on the medial ankle
C. Painless ulcer on the toes
D. Deep ulcer with purulent drainage
CORRECT ANSWER: A. Severe pain, pale skin, and decreased pulses
Rationale: Arterial ulcers present with severe pain, pale skin, decreased pulses, and
cool extremities. They are typically located on the toes, heels, or lateral malleolus.
Question 10: A nurse is caring for a client with an arterial ulcer. Which intervention
is priority?
A. Keep the leg dependent and avoid compression
B. Apply compression therapy
C. Elevate the leg above the heart
D. Restrict all activity
CORRECT ANSWER: A. Keep the leg dependent and avoid compression
Rationale: Arterial ulcers require improved perfusion. Keeping the leg dependent and
avoiding compression promotes blood flow. Elevation and compression are
contraindicated.
Question 11: A nurse is assessing a client with a venous ulcer. Which finding is most
characteristic?
A. Severe pain, pale skin, and decreased pulses
B. Edema, warm skin, and ulcers on the medial ankle
C. Painless ulcer on the toes
D. Deep ulcer with purulent drainage
, CORRECT ANSWER: B. Edema, warm skin, and ulcers on the medial ankle
Rationale: Venous ulcers present with edema, warm skin, and ulcers on the medial
ankle. They are caused by venous insu iciency and are treated with compression
therapy.
Question 12: A nurse is caring for a client with a venous ulcer. Which intervention is
priority?
A. Apply compression therapy and elevate the leg
B. Keep the leg dependent
C. Restrict all activity
D. Apply heat to the wound
CORRECT ANSWER: A. Apply compression therapy and elevate the leg
Rationale: Venous ulcer management includes compression therapy, leg elevation,
wound care, and exercise. Compression improves venous return and promotes healing.
Question 13: A nurse is assessing a client with a diabetic foot ulcer. Which finding is
most concerning?
A. Mild pain
B. Deep ulcer with purulent drainage and signs of infection
C. Decreased breath sounds
D. Pleuritic chest pain
CORRECT ANSWER: B. Deep ulcer with purulent drainage and signs of infection
Rationale: Diabetic foot ulcers with purulent drainage and signs of infection require
immediate intervention, including antibiotics and debridement.
Question 14: A nurse is teaching a client with diabetes about foot care. Which
statement indicates correct understanding?
A. "I will inspect my feet daily and wear properly fitting shoes."
B. "I will soak my feet in hot water daily."
C. "I will cut my corns with a razor."
D. "I will walk barefoot at home."
CORRECT ANSWER: A. "I will inspect my feet daily and wear properly fitting shoes."
Rationale: Daily foot inspection and properly fitting shoes prevent foot ulcers. Clients
should avoid soaking feet in hot water, cutting corns, and walking barefoot.
Question 15: A nurse is assessing a client with a burn injury. Which finding indicates
a superficial (first-degree) burn?
characteristic of a Stage I pressure ulcer?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: A. Intact skin with nonblanchable redness
Rationale: A Stage I pressure ulcer presents as intact skin with nonblanchable redness
over a bony prominence. Early recognition and pressure relief prevent progression to
more advanced stages.
Question 2: A nurse is assessing a client with a Stage II pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: B. Partial-thickness skin loss with a shallow open ulcer
Rationale: A Stage II pressure ulcer involves partial-thickness loss of the dermis,
presenting as a shallow open ulcer with a red-pink wound bed or a blister. It requires
moist wound healing and pressure relief.
Question 3: A nurse is assessing a client with a Stage III pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: C. Full-thickness tissue loss with visible subcutaneous fat
Rationale: A Stage III pressure ulcer involves full-thickness tissue loss with visible
subcutaneous fat but no exposed bone, tendon, or muscle. Slough may be present but
does not obscure the depth of tissue loss.
Question 4: A nurse is assessing a client with a Stage IV pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss with a shallow open ulcer
,C. Full-thickness tissue loss with visible subcutaneous fat
D. Full-thickness loss with exposed bone, tendon, or muscle
CORRECT ANSWER: D. Full-thickness loss with exposed bone, tendon, or muscle
Rationale: A Stage IV pressure ulcer involves full-thickness tissue loss with exposed
bone, tendon, or muscle. It requires aggressive wound care and may necessitate
surgical intervention.
Question 5: A nurse is assessing a client with an unstageable pressure ulcer. Which
finding is expected?
A. Intact skin with nonblanchable redness
B. Partial-thickness skin loss
C. Full-thickness tissue loss obscured by slough or eschar
D. Full-thickness loss with exposed bone
CORRECT ANSWER: C. Full-thickness tissue loss obscured by slough or eschar
Rationale: An unstageable pressure ulcer involves full-thickness tissue loss obscured
by slough or eschar. The wound cannot be staged until the slough or eschar is removed.
Question 6: A nurse is assessing a client with a deep tissue injury. Which finding is
expected?
A. Intact skin with nonblanchable redness
B. Purple or maroon localized area of discolored intact skin
C. Full-thickness tissue loss
D. Exposed bone, tendon, or muscle
CORRECT ANSWER: B. Purple or maroon localized area of discolored intact skin
Rationale: A deep tissue injury presents as a purple or maroon localized area of
discolored intact skin or a blood-filled blister. It may evolve into a full-thickness ulcer.
Question 7: A nurse is caring for a client at risk for pressure ulcers. Which
intervention is priority?
A. Reposition the client every 2 hours
B. Keep the client in one position
C. Restrict all fluids
D. Massage reddened areas
CORRECT ANSWER: A. Reposition the client every 2 hours
Rationale: Repositioning every 2 hours relieves pressure over bony prominences and
prevents pressure ulcer development. Massaging reddened areas can cause further
tissue damage.
,Question 8: A nurse is using the Braden Scale to assess a client's risk for pressure
ulcers. Which score indicates the highest risk?
A. Score of 23
B. Score of 18
C. Score of 12
D. Score of 6
CORRECT ANSWER: D. Score of 6
Rationale: The Braden Scale ranges from 6 to 23, with lower scores indicating higher
risk. A score of 6 indicates severe risk for pressure ulcer development.
Question 9: A nurse is assessing a client with a suspected arterial ulcer. Which
finding is most characteristic?
A. Severe pain, pale skin, and decreased pulses
B. Edema, warm skin, and ulcers on the medial ankle
C. Painless ulcer on the toes
D. Deep ulcer with purulent drainage
CORRECT ANSWER: A. Severe pain, pale skin, and decreased pulses
Rationale: Arterial ulcers present with severe pain, pale skin, decreased pulses, and
cool extremities. They are typically located on the toes, heels, or lateral malleolus.
Question 10: A nurse is caring for a client with an arterial ulcer. Which intervention
is priority?
A. Keep the leg dependent and avoid compression
B. Apply compression therapy
C. Elevate the leg above the heart
D. Restrict all activity
CORRECT ANSWER: A. Keep the leg dependent and avoid compression
Rationale: Arterial ulcers require improved perfusion. Keeping the leg dependent and
avoiding compression promotes blood flow. Elevation and compression are
contraindicated.
Question 11: A nurse is assessing a client with a venous ulcer. Which finding is most
characteristic?
A. Severe pain, pale skin, and decreased pulses
B. Edema, warm skin, and ulcers on the medial ankle
C. Painless ulcer on the toes
D. Deep ulcer with purulent drainage
, CORRECT ANSWER: B. Edema, warm skin, and ulcers on the medial ankle
Rationale: Venous ulcers present with edema, warm skin, and ulcers on the medial
ankle. They are caused by venous insu iciency and are treated with compression
therapy.
Question 12: A nurse is caring for a client with a venous ulcer. Which intervention is
priority?
A. Apply compression therapy and elevate the leg
B. Keep the leg dependent
C. Restrict all activity
D. Apply heat to the wound
CORRECT ANSWER: A. Apply compression therapy and elevate the leg
Rationale: Venous ulcer management includes compression therapy, leg elevation,
wound care, and exercise. Compression improves venous return and promotes healing.
Question 13: A nurse is assessing a client with a diabetic foot ulcer. Which finding is
most concerning?
A. Mild pain
B. Deep ulcer with purulent drainage and signs of infection
C. Decreased breath sounds
D. Pleuritic chest pain
CORRECT ANSWER: B. Deep ulcer with purulent drainage and signs of infection
Rationale: Diabetic foot ulcers with purulent drainage and signs of infection require
immediate intervention, including antibiotics and debridement.
Question 14: A nurse is teaching a client with diabetes about foot care. Which
statement indicates correct understanding?
A. "I will inspect my feet daily and wear properly fitting shoes."
B. "I will soak my feet in hot water daily."
C. "I will cut my corns with a razor."
D. "I will walk barefoot at home."
CORRECT ANSWER: A. "I will inspect my feet daily and wear properly fitting shoes."
Rationale: Daily foot inspection and properly fitting shoes prevent foot ulcers. Clients
should avoid soaking feet in hot water, cutting corns, and walking barefoot.
Question 15: A nurse is assessing a client with a burn injury. Which finding indicates
a superficial (first-degree) burn?
