NURSING FUNDAMENTALS EXAM
TEST BANK NURSING FUNDAMENTALS
EXAM 3 VERSIONS { EXAMS 1 , 2 & 3 }
LATEST ACTUAL EXAM COMPLETE
EACH 250 QUESTIONS AND CORRECT
DETAILED ANSWERS (RATIONALES )
|ALREADY GRADED A+||BRAND
NEW VERSION!!
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
A+ TEST BANK 1
, NURSING FUNDAMENTALS EXAM
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 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.
A+ TEST BANK 2
, NURSING FUNDAMENTALS EXAM
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
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer –
Correct Answer :ANS: C
A+ TEST BANK 3
, NURSING FUNDAMENTALS EXAM
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 crater. Stage I is intact skin with nonblanchable redness over a
bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but
bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with
exposed bone, tendon, or muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light –
A+ TEST BANK 4
TEST BANK NURSING FUNDAMENTALS
EXAM 3 VERSIONS { EXAMS 1 , 2 & 3 }
LATEST ACTUAL EXAM COMPLETE
EACH 250 QUESTIONS AND CORRECT
DETAILED ANSWERS (RATIONALES )
|ALREADY GRADED A+||BRAND
NEW VERSION!!
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
A+ TEST BANK 1
, NURSING FUNDAMENTALS EXAM
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 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.
A+ TEST BANK 2
, NURSING FUNDAMENTALS EXAM
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
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer –
Correct Answer :ANS: C
A+ TEST BANK 3
, NURSING FUNDAMENTALS EXAM
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 crater. Stage I is intact skin with nonblanchable redness over a
bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but
bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with
exposed bone, tendon, or muscle.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin.
Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light –
A+ TEST BANK 4
