NR-224 Exam 2 | Original Practice Examination | 2026/2027 1
, NR-224 EXAM 2
Fundamentals - Skills
Chamberlain University
100-Question Original Practice Examination
2026/2027 Edition
1. A bedbound adult has nonblanchable redness over the sacrum with intact skin. How should this
findingbe classified?
A) Stage 2 pressure injury
B) Stage 1 pressure injury
C) Deep-tissue pressure injury
D) Moisture-associated dermatitis
Correct Answer: B) Stage 1 pressure injury
Rationale: Intact skin with persistent nonblanchable erythema meets stage 1 criteria. Stage 2 requires partial-thickness skin
loss.
Deep-tissue injury typically has persistent deep red, maroon, or purple discoloration. Relieve pressure and monitor skin closely.
2. A shallow open heel wound has a pink moist bed with no visible fat. Which stage is most consistent?
A) Stage 1 pressure injury
B) Stage 3 pressure injury
C) Unstageable pressure injury
D) Stage 2 pressure injury
Correct Answer: D) Stage 2 pressure injury
Rationale: Partial-thickness skin loss with an exposed viable dermis fits stage 2. Visible subcutaneous fat indicates stage 3,
while slough obscuring the base may make staging impossible. Avoid classifying skin tears as pressure injuries without
confirming etiology.
3. A sacral wound base is completely covered with thick yellow slough. How should depth be
documented?
A) Unstageable pressure injury
B) Stage 2 pressure injury
C) Stage 3 pressure injury
D) Stage 1 pressure injury
Correct Answer: A) Unstageable pressure injury
Rationale: When slough or eschar obscures the extent of tissue loss, the wound cannot be accurately staged. It is unstageable
until enough obscuring material is removed when clinically appropriate. Do not guess the underlying depth.
4. A dark purple area develops on a patient's heel after prolonged pressure, although skin remains intact.
What is the priority interpretation?
A) Normal bruising that requires no action
B) Possible deep-tissue pressure injury
NR-224 Exam 2 | Original Practice Examination | 2026/2027 2
, C) Stage 1 pressure injury by definition
D) Stage 2 pressure injury
Correct Answer: B) Possible deep-tissue pressure injury
Rationale: Persistent maroon or purple discoloration can indicate deeper tissue damage despite intact skin. Stage 1 is generally
nonblanchable erythema rather than purple discoloration. Offload pressure, evaluate tissue and document promptly.
5. During wound inspection, thick green drainage and a new foul odor are observed. What should the
nursedo?
A) Seal the wound without reassessment
B) Assume the drainage proves normal healing
C) Apply direct pressure until drainage stops
D) Assess for infection and report the change
Correct Answer: D) Assess for infection and report the change
Rationale: New malodorous or purulent drainage warrants assessment for local or systemic infection and prompt
communication.
Color alone does not establish a definitive diagnosis. Check surrounding erythema, warmth, pain, fever, and ordered cultures.
6. A postoperative dressing has pink watery drainage. Which documentation is most accurate?
A) Serosanguineous exudate
B) Sanguineous exudate
C) Purulent exudate
D) No drainage present
Correct Answer: A) Serosanguineous exudate
Rationale: A mixture of blood and serous fluid produces pink or pale red thin drainage called serosanguineous. Describe
amount, appearance, odor, and condition of surrounding skin rather than interpreting the finding in isolation.
7. When measuring a wound, what method supports consistent follow-up?
A) Estimate the wound size by visual impression alone
B) Measure the widest diagonal only
C) Record length head-to-toe, width side-to-side, and depth
D) Document depth only if tunneling is absent
Correct Answer: C) Record length head-to-toe, width side-to-side, and depth
Rationale: Standardized dimensions make healing trends comparable across assessments. Length is usually measured head-
to-toe, width perpendicular, and depth with an appropriate sterile instrument according to policy. Also describe tunneling and
undermining when present.
8. A wound edge separates several days after surgery without visible organs. Which complication
isoccurring?
A) Evisceration
B) Dehiscence
C) Maceration
D) Granulation
NR-224 Exam 2 | Original Practice Examination | 2026/2027 3
, NR-224 EXAM 2
Fundamentals - Skills
Chamberlain University
100-Question Original Practice Examination
2026/2027 Edition
1. A bedbound adult has nonblanchable redness over the sacrum with intact skin. How should this
findingbe classified?
A) Stage 2 pressure injury
B) Stage 1 pressure injury
C) Deep-tissue pressure injury
D) Moisture-associated dermatitis
Correct Answer: B) Stage 1 pressure injury
Rationale: Intact skin with persistent nonblanchable erythema meets stage 1 criteria. Stage 2 requires partial-thickness skin
loss.
Deep-tissue injury typically has persistent deep red, maroon, or purple discoloration. Relieve pressure and monitor skin closely.
2. A shallow open heel wound has a pink moist bed with no visible fat. Which stage is most consistent?
A) Stage 1 pressure injury
B) Stage 3 pressure injury
C) Unstageable pressure injury
D) Stage 2 pressure injury
Correct Answer: D) Stage 2 pressure injury
Rationale: Partial-thickness skin loss with an exposed viable dermis fits stage 2. Visible subcutaneous fat indicates stage 3,
while slough obscuring the base may make staging impossible. Avoid classifying skin tears as pressure injuries without
confirming etiology.
3. A sacral wound base is completely covered with thick yellow slough. How should depth be
documented?
A) Unstageable pressure injury
B) Stage 2 pressure injury
C) Stage 3 pressure injury
D) Stage 1 pressure injury
Correct Answer: A) Unstageable pressure injury
Rationale: When slough or eschar obscures the extent of tissue loss, the wound cannot be accurately staged. It is unstageable
until enough obscuring material is removed when clinically appropriate. Do not guess the underlying depth.
4. A dark purple area develops on a patient's heel after prolonged pressure, although skin remains intact.
What is the priority interpretation?
A) Normal bruising that requires no action
B) Possible deep-tissue pressure injury
NR-224 Exam 2 | Original Practice Examination | 2026/2027 2
, C) Stage 1 pressure injury by definition
D) Stage 2 pressure injury
Correct Answer: B) Possible deep-tissue pressure injury
Rationale: Persistent maroon or purple discoloration can indicate deeper tissue damage despite intact skin. Stage 1 is generally
nonblanchable erythema rather than purple discoloration. Offload pressure, evaluate tissue and document promptly.
5. During wound inspection, thick green drainage and a new foul odor are observed. What should the
nursedo?
A) Seal the wound without reassessment
B) Assume the drainage proves normal healing
C) Apply direct pressure until drainage stops
D) Assess for infection and report the change
Correct Answer: D) Assess for infection and report the change
Rationale: New malodorous or purulent drainage warrants assessment for local or systemic infection and prompt
communication.
Color alone does not establish a definitive diagnosis. Check surrounding erythema, warmth, pain, fever, and ordered cultures.
6. A postoperative dressing has pink watery drainage. Which documentation is most accurate?
A) Serosanguineous exudate
B) Sanguineous exudate
C) Purulent exudate
D) No drainage present
Correct Answer: A) Serosanguineous exudate
Rationale: A mixture of blood and serous fluid produces pink or pale red thin drainage called serosanguineous. Describe
amount, appearance, odor, and condition of surrounding skin rather than interpreting the finding in isolation.
7. When measuring a wound, what method supports consistent follow-up?
A) Estimate the wound size by visual impression alone
B) Measure the widest diagonal only
C) Record length head-to-toe, width side-to-side, and depth
D) Document depth only if tunneling is absent
Correct Answer: C) Record length head-to-toe, width side-to-side, and depth
Rationale: Standardized dimensions make healing trends comparable across assessments. Length is usually measured head-
to-toe, width perpendicular, and depth with an appropriate sterile instrument according to policy. Also describe tunneling and
undermining when present.
8. A wound edge separates several days after surgery without visible organs. Which complication
isoccurring?
A) Evisceration
B) Dehiscence
C) Maceration
D) Granulation
NR-224 Exam 2 | Original Practice Examination | 2026/2027 3
