Nursing 204 Exam 2 Questions With
Real Solutions Graded A+
Decreased level of consciousness - CORRECT ANSWER-A nurse participating in a
research project associated with pressure ulcers will assess for what predisposing
factor that tends to increase the risk for pressure ulcer development?
A. Decreased level of consciousness
B. Adequate dietary intake
C. Shortness of breath
D. Muscular pain
Healing stage III pressure ulcer - CORRECT ANSWER-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?
1. stage 1 pressure ulcer
2. healing stage II pressure ulcer
3. Healing stage III pressure ulcer
4. Stage III pressure ulcer
Stage II - CORRECT ANSWER-The nurse admitting an older patient notes a shallow
open reddish, pink ulcer without slough on the right heel of the patient. How will the
nurse stage this pressure ulcer?
1. Stage 1
2. Stage II
3. Stage III
4. Stave IV
,Natural Light - CORRECT ANSWER-Which item should the nurse use to first assist in
staging an ulcer on the heel of a darkly pigmented skin patient?
a. disposable measuring tape
b. cotton-tipped applicator
c. sterile gloves
d. natural light
pressure - CORRECT ANSWER-The nurse caring for an unconscious patient who was
involved in an automobile accident 2 weeks ago will give priority to which element when
planning care to decrease the development o fa decubitus ulcer?
a. Resistance
b. pressure
c. weight
d. stress
fecal incontinence - CORRECT ANSWER-which nursing observation will indicate the
patient is at risk for pressure ulcer formation?
a. fecal incontinence
b. ate two thirds of breakfast
c. A raised red rash on the right shin
Full thickness wound repair - CORRECT ANSWER-The nurse is caring for a patient
with a stage IV pressure ulcer. Which type of healing will the nurse consider when
planning care for this patient?
a. partial thickness wound repair
b. full thickness wound repair
c. primary intention
, d. tertiary intention
A patient with appendicitis using a heating pad - CORRECT ANSWER-The nurse is
caring for a group of patients. Which patient will the nurse see first?
a. A patient with stage IV pressure ulcer
b. a patient with a braden scale score of 18
c. a patient with appendicitis using a heating pad
d. a patient with an incision that is approximated
granulation - CORRECT ANSWER-The nurse is caring for a patient who is experiencing
a full thickness wound repair. Which type of tissue will the nurse expect to observe
when the wound is healing?
a. eschar
b. slough
c. granulation
d. purulent drainage
Primary intention - CORRECT ANSWER-The nurse is caring for a patient who has
experienced a laparoscopic appendectomy. For which type of healing will the nurse
focus the care plan ?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
Secondary intention - CORRECT ANSWER-The nurse is caring for a patient in the burn
unit should expect what type of wound healing when planning care for this patient?
a. partial-thickness repair
Real Solutions Graded A+
Decreased level of consciousness - CORRECT ANSWER-A nurse participating in a
research project associated with pressure ulcers will assess for what predisposing
factor that tends to increase the risk for pressure ulcer development?
A. Decreased level of consciousness
B. Adequate dietary intake
C. Shortness of breath
D. Muscular pain
Healing stage III pressure ulcer - CORRECT ANSWER-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?
1. stage 1 pressure ulcer
2. healing stage II pressure ulcer
3. Healing stage III pressure ulcer
4. Stage III pressure ulcer
Stage II - CORRECT ANSWER-The nurse admitting an older patient notes a shallow
open reddish, pink ulcer without slough on the right heel of the patient. How will the
nurse stage this pressure ulcer?
1. Stage 1
2. Stage II
3. Stage III
4. Stave IV
,Natural Light - CORRECT ANSWER-Which item should the nurse use to first assist in
staging an ulcer on the heel of a darkly pigmented skin patient?
a. disposable measuring tape
b. cotton-tipped applicator
c. sterile gloves
d. natural light
pressure - CORRECT ANSWER-The nurse caring for an unconscious patient who was
involved in an automobile accident 2 weeks ago will give priority to which element when
planning care to decrease the development o fa decubitus ulcer?
a. Resistance
b. pressure
c. weight
d. stress
fecal incontinence - CORRECT ANSWER-which nursing observation will indicate the
patient is at risk for pressure ulcer formation?
a. fecal incontinence
b. ate two thirds of breakfast
c. A raised red rash on the right shin
Full thickness wound repair - CORRECT ANSWER-The nurse is caring for a patient
with a stage IV pressure ulcer. Which type of healing will the nurse consider when
planning care for this patient?
a. partial thickness wound repair
b. full thickness wound repair
c. primary intention
, d. tertiary intention
A patient with appendicitis using a heating pad - CORRECT ANSWER-The nurse is
caring for a group of patients. Which patient will the nurse see first?
a. A patient with stage IV pressure ulcer
b. a patient with a braden scale score of 18
c. a patient with appendicitis using a heating pad
d. a patient with an incision that is approximated
granulation - CORRECT ANSWER-The nurse is caring for a patient who is experiencing
a full thickness wound repair. Which type of tissue will the nurse expect to observe
when the wound is healing?
a. eschar
b. slough
c. granulation
d. purulent drainage
Primary intention - CORRECT ANSWER-The nurse is caring for a patient who has
experienced a laparoscopic appendectomy. For which type of healing will the nurse
focus the care plan ?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
Secondary intention - CORRECT ANSWER-The nurse is caring for a patient in the burn
unit should expect what type of wound healing when planning care for this patient?
a. partial-thickness repair
