NSG 101 EXAM #4 QUESTIONS WITH CORRECT ANSWERS LATEST UPDATE 2026
When should discharge planning begin? - Answers Upon admission to the facility
Which finding indicates postponing discharge teaching? - Answers Pain
What action should a nurse take if a client reports cramping during a cleansing enema? - Answers
Lower the height of the solution container
What is the correct description of a stage 1 pressure injury? - Answers Intact skin with localized
nonblanchable erythema
What indicates a stage 2 pressure injury? - Answers Partial-thickness skin loss with red tissue in
wound bed
What describes a stage 3 pressure injury? - Answers Full thickness tissue loss with visible
subcutaneous fat
What stage is indicated by a deep crater with exposed tendon? - Answers Stage 4
What is the nurse's priority action if a client's abdominal incision opens and bowel protrudes? -
Answers Cover with sterile gauze moistened with normal saline
What describes dehiscence in wound complications? - Answers The wound edges open along the
incision
What finding indicates wound infection? - Answers Edema and purulent drainage
What action contaminates a sterile field? - Answers Placing sterile supplies within 2.5 cm (1 in) border
Which action maintains sterility during a sterile procedure? - Answers Keeping the sterile field in sight
at all times
What complication should a nurse monitor for during the Valsalva maneuver? - Answers Bradycardia
How can a client with a colostomy reduce gas and odor? - Answers Eating yogurt can decrease odor
What is granulation tissue? - Answers Soft, red tissue that bleeds easily
What is secondary intention healing? - Answers The wound is left open and heals from the bottom up
What indicates a wound is healing by primary intention? - Answers The wound edges are sutured and
closed
Which nutrient is a priority for wound healing? - Answers Vitamin C
What does increased protein intake support in wound healing? - Answers Collagen formation and
tissue repair
What intervention should be recommended for a client with constipation? - Answers Increase fiber
and fluids
What is the expected outcome of preoperative teaching? - Answers Decreased post-op anxiety
What increases pressure injury risk in clients with impaired mobility? - Answers Decreased circulation
Which dressing is appropriate for a stage 1 pressure injury? - Answers Transparent dressing
What lab value suggests infection in a client with a pressure ulcer? - Answers High WBC
What is the appropriate action for disposing of a soiled dressing? - Answers Place dressing in a
biohazard waste container
Where should a client expect the stoma to be located for an ileostomy? - Answers Lower right
abdomen
What is correct about the epidermis? - Answers It is avascular and receives nutrition from the dermis
What is avascular and receives nutrition from the dermis? - Answers The skin
Which dressing is most appropriate for a wound with significant exudate? - Answers Hydrofiber
dressing
Which dressing is best for a superficial wound with no exudate? - Answers Transparent film dressing
What instruction helps reduce the risk for skin breakdown? - Answers Apply moisturizer after cleaning
Which cells determine skin color? - Answers Melanocytes
What complication is a risk for a client with a chronic wound? - Answers Psychological distress
What does nonblanchable erythema on the heel indicate? - Answers Stage 1 pressure injury
What factors increase the risk for delayed wound healing? - Answers Poor nutrition, Diabetes
mellitus, Infection present, Smoking
Which changes to skin integrity should be reported? - Answers Nonblanchable redness over bony
areas, Warmth and swelling at a wound site, Purple/maroon discoloration over pressure area, New
open blister or skin tear
What are potential adverse effects of medications on skin and wound healing? - Answers Constipation
from opioid analgesics, Delayed wound healing from corticosteroids, Increased bleeding risk from
anticoagulants, Hypoglycemia from insulin
When should discharge planning begin? - Answers Upon admission to the facility
Which finding indicates postponing discharge teaching? - Answers Pain
What action should a nurse take if a client reports cramping during a cleansing enema? - Answers
Lower the height of the solution container
What is the correct description of a stage 1 pressure injury? - Answers Intact skin with localized
nonblanchable erythema
What indicates a stage 2 pressure injury? - Answers Partial-thickness skin loss with red tissue in
wound bed
What describes a stage 3 pressure injury? - Answers Full thickness tissue loss with visible
subcutaneous fat
What stage is indicated by a deep crater with exposed tendon? - Answers Stage 4
What is the nurse's priority action if a client's abdominal incision opens and bowel protrudes? -
Answers Cover with sterile gauze moistened with normal saline
What describes dehiscence in wound complications? - Answers The wound edges open along the
incision
What finding indicates wound infection? - Answers Edema and purulent drainage
What action contaminates a sterile field? - Answers Placing sterile supplies within 2.5 cm (1 in) border
Which action maintains sterility during a sterile procedure? - Answers Keeping the sterile field in sight
at all times
What complication should a nurse monitor for during the Valsalva maneuver? - Answers Bradycardia
How can a client with a colostomy reduce gas and odor? - Answers Eating yogurt can decrease odor
What is granulation tissue? - Answers Soft, red tissue that bleeds easily
What is secondary intention healing? - Answers The wound is left open and heals from the bottom up
What indicates a wound is healing by primary intention? - Answers The wound edges are sutured and
closed
Which nutrient is a priority for wound healing? - Answers Vitamin C
What does increased protein intake support in wound healing? - Answers Collagen formation and
tissue repair
What intervention should be recommended for a client with constipation? - Answers Increase fiber
and fluids
What is the expected outcome of preoperative teaching? - Answers Decreased post-op anxiety
What increases pressure injury risk in clients with impaired mobility? - Answers Decreased circulation
Which dressing is appropriate for a stage 1 pressure injury? - Answers Transparent dressing
What lab value suggests infection in a client with a pressure ulcer? - Answers High WBC
What is the appropriate action for disposing of a soiled dressing? - Answers Place dressing in a
biohazard waste container
Where should a client expect the stoma to be located for an ileostomy? - Answers Lower right
abdomen
What is correct about the epidermis? - Answers It is avascular and receives nutrition from the dermis
What is avascular and receives nutrition from the dermis? - Answers The skin
Which dressing is most appropriate for a wound with significant exudate? - Answers Hydrofiber
dressing
Which dressing is best for a superficial wound with no exudate? - Answers Transparent film dressing
What instruction helps reduce the risk for skin breakdown? - Answers Apply moisturizer after cleaning
Which cells determine skin color? - Answers Melanocytes
What complication is a risk for a client with a chronic wound? - Answers Psychological distress
What does nonblanchable erythema on the heel indicate? - Answers Stage 1 pressure injury
What factors increase the risk for delayed wound healing? - Answers Poor nutrition, Diabetes
mellitus, Infection present, Smoking
Which changes to skin integrity should be reported? - Answers Nonblanchable redness over bony
areas, Warmth and swelling at a wound site, Purple/maroon discoloration over pressure area, New
open blister or skin tear
What are potential adverse effects of medications on skin and wound healing? - Answers Constipation
from opioid analgesics, Delayed wound healing from corticosteroids, Increased bleeding risk from
anticoagulants, Hypoglycemia from insulin
