Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
Assessment of M.J.'s right trochanter reveals a shallow open ulcer with a red pink
wound bed. This ulcer would be graded as:
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable. - Answer- b. A stage II ulcer: reveals partial thickness loss of
dermis presenting as a shallow open ulcer with a red pink wound bed, without
slough. It may also present as an intact or open/ruptured serum-filled blister.
The skin on M.J.'s scapulae is intact but is boggy to touch and purple. You identify
this assessment finding as:
a. a stage I pressure ulcer.
b. a normal finding for an African-American patient.
c. unstageable as a result of ethnic variations in skin tone.
d. indicative of a high risk for pressure ulcer formation in that area.
- Answer- a. Stage I pressure ulcer: In a patient with darker skin tones, you need
to look for changes in skin color, such as skin that is darker (purplish, brownish,
bluish) than surrounding skin. You should also touch the skin to feel its
consistency. A boggy or edematous feel may indicate a stage I pressure ulcer.
The pressure ulcer on M.J.'s left trochanter is covered with eschar. You grade this
ulcer as:
,Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable
. - Answer- e. Unstageable: When eschar is present, accurate staging of the
pressure ulcer is not possible until enough eschar is removed to expose the base of
the wound.
In planning care for M.J., you identify all the risk factors for pressure ulcers that
he has. Select those factors that you know apply to M.J. –
Answer- Older age
Contractures
Immobility
Incontinence
Neurologic disorders
Pain
THESE DO NOT APPLY:
NO: Anemia
NO: Diabetes mellitus
NO: Elevated body temperature
NO:Impaired circulation
NO: Low diastolic blood pressure (< 60)
NO: Mental deterioration
NO: Obesity
NO: Prolonged surgery
NO: Vascular disease
,Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
Using the Braden Scale, you complete M.J.'s risk assessment with the following
scores obtained: sensory perception - 2, moisture - 3, activity - 1, mobility - 1,
nutrition - 2, friction and shear - 1. TOTAL SCORE 10
- Answer- The patient's risk level is HIGH risk.
You measure and stage M.J.'s pressure ulcers and clean them with saline. What
equipment should you use to best cleanse the pressure ulcers without causing
trauma or damage to the wound?
A. Q-tips and 2 × 2 gauze
B. 4 × 4 gauze pads and a basin
C. 10-mL syringe with a 25-gauge needle
D. 30-mL syringe with a 19-gauge needle
- Answer- D. 30-mL syringe with a 19-gauge needle: It is important to use enough
irrigation pressure to adequately clean the pressure ulcer (4 to 15 psi) without
causing trauma or damage to the wound. To obtain this pressure, a 30-mL syringe
and a 19-gauge needle can be used.
There is a moderate amount of yellow drainage from the sacral ulcer, serous
drainage from the right trochanter ulcer, and no drainage from the left trochanter
ulcer. There is black, necrotic tissue in the sacral ulcer, and the left trochanter
ulcer is covered with eschar. You recognize that further care of these pressure
ulcers requires:
A. removal of the necrotic tissue and eschar.
B. application of a dry dressing that will absorb any drainage.
, Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
C. the application of local antiseptic agents, such as povidone iodine.
D. the use of transparent polyurethane films to keep the wound moist.
- Answer- A. Removal of the necrotic tissue and eschar.
In order to establish a clean granulating base for healing, necrotic tissue and
eschar must be removed from the ulcer. The debridement method used to remove
necrotic tissue can be surgical, mechanical, enzymatic, or autolytic and should be
discussed with the health care provider. Eschar is removed by cutting it away.
Antiseptic solutions are cytotoxic and should not be used to clean or soak
pressure ulcers. Dry dressings should not be used on newly granulating tissue,
and transparent polyurethane films are appropriate for superficial wounds
without drainage.
Dietitian ROLE
- Answer- Evaluation of nutritional status
Recommendations for nutritional supplements
Home Health Aide ROLE
- Answer- Assist with personal care such as bathing and hygiene
Light housekeeping and meal preparation
Social Worker ROLE
- Answer- Assist with managing financial resources
Referral to volunteer MS agencies
Physician ROLE –
Answer- Medical monitoring of condition
Medical & surgical strategies for pressure ulcer trtmt.
Clinical Case Studies & Answers
| 2025/2026 Edition
Assessment of M.J.'s right trochanter reveals a shallow open ulcer with a red pink
wound bed. This ulcer would be graded as:
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable. - Answer- b. A stage II ulcer: reveals partial thickness loss of
dermis presenting as a shallow open ulcer with a red pink wound bed, without
slough. It may also present as an intact or open/ruptured serum-filled blister.
The skin on M.J.'s scapulae is intact but is boggy to touch and purple. You identify
this assessment finding as:
a. a stage I pressure ulcer.
b. a normal finding for an African-American patient.
c. unstageable as a result of ethnic variations in skin tone.
d. indicative of a high risk for pressure ulcer formation in that area.
- Answer- a. Stage I pressure ulcer: In a patient with darker skin tones, you need
to look for changes in skin color, such as skin that is darker (purplish, brownish,
bluish) than surrounding skin. You should also touch the skin to feel its
consistency. A boggy or edematous feel may indicate a stage I pressure ulcer.
The pressure ulcer on M.J.'s left trochanter is covered with eschar. You grade this
ulcer as:
,Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
a. stage I.
b. stage II.
c. stage III.
d. stage IV.
e. unstageable
. - Answer- e. Unstageable: When eschar is present, accurate staging of the
pressure ulcer is not possible until enough eschar is removed to expose the base of
the wound.
In planning care for M.J., you identify all the risk factors for pressure ulcers that
he has. Select those factors that you know apply to M.J. –
Answer- Older age
Contractures
Immobility
Incontinence
Neurologic disorders
Pain
THESE DO NOT APPLY:
NO: Anemia
NO: Diabetes mellitus
NO: Elevated body temperature
NO:Impaired circulation
NO: Low diastolic blood pressure (< 60)
NO: Mental deterioration
NO: Obesity
NO: Prolonged surgery
NO: Vascular disease
,Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
Using the Braden Scale, you complete M.J.'s risk assessment with the following
scores obtained: sensory perception - 2, moisture - 3, activity - 1, mobility - 1,
nutrition - 2, friction and shear - 1. TOTAL SCORE 10
- Answer- The patient's risk level is HIGH risk.
You measure and stage M.J.'s pressure ulcers and clean them with saline. What
equipment should you use to best cleanse the pressure ulcers without causing
trauma or damage to the wound?
A. Q-tips and 2 × 2 gauze
B. 4 × 4 gauze pads and a basin
C. 10-mL syringe with a 25-gauge needle
D. 30-mL syringe with a 19-gauge needle
- Answer- D. 30-mL syringe with a 19-gauge needle: It is important to use enough
irrigation pressure to adequately clean the pressure ulcer (4 to 15 psi) without
causing trauma or damage to the wound. To obtain this pressure, a 30-mL syringe
and a 19-gauge needle can be used.
There is a moderate amount of yellow drainage from the sacral ulcer, serous
drainage from the right trochanter ulcer, and no drainage from the left trochanter
ulcer. There is black, necrotic tissue in the sacral ulcer, and the left trochanter
ulcer is covered with eschar. You recognize that further care of these pressure
ulcers requires:
A. removal of the necrotic tissue and eschar.
B. application of a dry dressing that will absorb any drainage.
, Medical-Surgical Nursing I:
Clinical Case Studies & Answers
| 2025/2026 Edition
C. the application of local antiseptic agents, such as povidone iodine.
D. the use of transparent polyurethane films to keep the wound moist.
- Answer- A. Removal of the necrotic tissue and eschar.
In order to establish a clean granulating base for healing, necrotic tissue and
eschar must be removed from the ulcer. The debridement method used to remove
necrotic tissue can be surgical, mechanical, enzymatic, or autolytic and should be
discussed with the health care provider. Eschar is removed by cutting it away.
Antiseptic solutions are cytotoxic and should not be used to clean or soak
pressure ulcers. Dry dressings should not be used on newly granulating tissue,
and transparent polyurethane films are appropriate for superficial wounds
without drainage.
Dietitian ROLE
- Answer- Evaluation of nutritional status
Recommendations for nutritional supplements
Home Health Aide ROLE
- Answer- Assist with personal care such as bathing and hygiene
Light housekeeping and meal preparation
Social Worker ROLE
- Answer- Assist with managing financial resources
Referral to volunteer MS agencies
Physician ROLE –
Answer- Medical monitoring of condition
Medical & surgical strategies for pressure ulcer trtmt.
