Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
1. The nurse is working on a medical-surgical unit that
has been participating in a research project associated
with pressure ulcers. The nurse recognizes that the risk
factors that predispose a patient to pressure ulcer
development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - correct answer ✅✅ANS: B
Patients who are confused or disoriented or who have
changing levels of consciousness are unable to protect
themselves. The patient may feel the pressure but may
not understand what to do to relieve the discomfort or to
communicate that he or she is feeling discomfort.
Impaired sensory perception, impaired mobility, shear,
friction, and moisture are other predisposing factors.
Shortness of breath, muscular pain, and a diet low in
calories and fat are not included among the predisposing
factors.
2. The nurse is caring for a patient who was involved in
an automobile accident 2 weeks ago. The patient
sustained a head injury and is unconscious. The nurse is
,Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
able to identify that the major element involved in the
development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight. - correct answer ✅✅ANS: A
Pressure is the main element that causes pressure ulcers.
Three pressure-related factors contribute to pressure
ulcer development: pressure intensity, pressure duration,
and tissue tolerance. When the intensity of the pressure
exerted on the capillary exceeds 12 to 32 mm Hg, this
occludes the vessel, causing ischemic injury to the
tissues it normally feeds. High pressure over a short time
and low pressure over a long time cause skin breakdown.
Resistance (the ability to remain unaltered by the
damaging effect of something), stress (worry or anxiety),
and weight (individuals of all sizes, shapes, and ages
acquire skin breakdown) are not major causes of pressure
ulcers.
3. Which nursing observation would indicate that the
patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
,Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds. -
correct answer ✅✅ANS: B
The presence and duration of moisture on the skin
increase the risk of ulcer formation by making it
susceptible to injury. Moisture can originate from wound
drainage, excessive perspiration, and fecal or urinary
incontinence. Bacteria and enzymes in the stool can
enhance the opportunity for skin breakdown because the
skin is moistened and softened, causing maceration.
Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that
the individual is at risk. A raised red rash on the leg again
is a concern and can affect the integrity of the skin, but it
is located on the shin, which is not a high-risk area for
skin breakdown. Pressure can influence capillary refill,
leading to skin breakdown, but this capillary response is
within normal limits.
4. The wound care nurse visits a patient in the long-term
care unit. The nurse is monitoring a patient with a stage
III pressure ulcer. The wound seems to be healing, and
healthy tissue is observed. How would the nurse stage
this ulcer?
a. Stage I pressure ulcer
, Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer - correct answer ✅✅ANS: C
When a pressure ulcer has been staged and is beginning
to heal, the ulcer keeps the same stage and is labeled
with the words "healing stage." Once an ulcer has been
staged, the stage endures even as the ulcer heals. This
ulcer was labeled a stage III, it cannot return to a previous
stage such as stage I or II. This ulcer is healing, so it is no
longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing
home. During the assessment, the nurse notes a shallow
open ulcer without slough on the right heel of the patient.
This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV. - correct answer ✅✅ANS: B
This would be a stage II pressure ulcer because it
presents as partial-thickness skin loss involving
epidermis, dermis, or both. The ulcer is superficial and
presents clinically as an abrasion, blister, or shallow
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
1. The nurse is working on a medical-surgical unit that
has been participating in a research project associated
with pressure ulcers. The nurse recognizes that the risk
factors that predispose a patient to pressure ulcer
development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain. - correct answer ✅✅ANS: B
Patients who are confused or disoriented or who have
changing levels of consciousness are unable to protect
themselves. The patient may feel the pressure but may
not understand what to do to relieve the discomfort or to
communicate that he or she is feeling discomfort.
Impaired sensory perception, impaired mobility, shear,
friction, and moisture are other predisposing factors.
Shortness of breath, muscular pain, and a diet low in
calories and fat are not included among the predisposing
factors.
2. The nurse is caring for a patient who was involved in
an automobile accident 2 weeks ago. The patient
sustained a head injury and is unconscious. The nurse is
,Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
able to identify that the major element involved in the
development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight. - correct answer ✅✅ANS: A
Pressure is the main element that causes pressure ulcers.
Three pressure-related factors contribute to pressure
ulcer development: pressure intensity, pressure duration,
and tissue tolerance. When the intensity of the pressure
exerted on the capillary exceeds 12 to 32 mm Hg, this
occludes the vessel, causing ischemic injury to the
tissues it normally feeds. High pressure over a short time
and low pressure over a long time cause skin breakdown.
Resistance (the ability to remain unaltered by the
damaging effect of something), stress (worry or anxiety),
and weight (individuals of all sizes, shapes, and ages
acquire skin breakdown) are not major causes of pressure
ulcers.
3. Which nursing observation would indicate that the
patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
,Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds. -
correct answer ✅✅ANS: B
The presence and duration of moisture on the skin
increase the risk of ulcer formation by making it
susceptible to injury. Moisture can originate from wound
drainage, excessive perspiration, and fecal or urinary
incontinence. Bacteria and enzymes in the stool can
enhance the opportunity for skin breakdown because the
skin is moistened and softened, causing maceration.
Eating a balanced diet is important for nutrition, but
eating just two thirds of the meal does not indicate that
the individual is at risk. A raised red rash on the leg again
is a concern and can affect the integrity of the skin, but it
is located on the shin, which is not a high-risk area for
skin breakdown. Pressure can influence capillary refill,
leading to skin breakdown, but this capillary response is
within normal limits.
4. The wound care nurse visits a patient in the long-term
care unit. The nurse is monitoring a patient with a stage
III pressure ulcer. The wound seems to be healing, and
healthy tissue is observed. How would the nurse stage
this ulcer?
a. Stage I pressure ulcer
, Fundamentals of Nursing Chapter 48:
Skin Integrity and Wound Care Practice
questions and A+ Guide answer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer - correct answer ✅✅ANS: C
When a pressure ulcer has been staged and is beginning
to heal, the ulcer keeps the same stage and is labeled
with the words "healing stage." Once an ulcer has been
staged, the stage endures even as the ulcer heals. This
ulcer was labeled a stage III, it cannot return to a previous
stage such as stage I or II. This ulcer is healing, so it is no
longer labeled a stage III.
5. The nurse is admitting an older patient from a nursing
home. During the assessment, the nurse notes a shallow
open ulcer without slough on the right heel of the patient.
This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV. - correct answer ✅✅ANS: B
This would be a stage II pressure ulcer because it
presents as partial-thickness skin loss involving
epidermis, dermis, or both. The ulcer is superficial and
presents clinically as an abrasion, blister, or shallow
