NUFT 204 EXAM #2 (SKIN INTEGRITY/WOUND CARE,
ACTIVITY/IMMOBILITY, ASSESSMENT TECHNIQUES,
HEAD/NECK/NEURO ASSESSMENT & RESPIRATORY)
2025/2026 COMPLETE QUESTIONS AND DETAILED
ANSWERS WITH RATIONALES || 100% GUARANTEED
PASS <LATEST VERSION>
Skin Integrity & Wound Care
1. A nurse is assessing a patient's pressure injury. The wound presents as a full-thickness skin
loss with exposed adipose tissue, but no bone, tendon, or muscle is visible. How should the
nurse stage this injury?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Rationale: Stage 3 pressure injuries involve full-thickness skin loss with damage or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia. Bone,
tendon, and muscle are not exposed.
2. When documenting the characteristics of a wound, the nurse notes a thick, yellow, foul-
smelling drainage. What term should the nurse use?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
Rationale: Purulent exudate is thick, often yellow, green, or brown, and indicates an infectious
process. The foul smell is a classic sign of infection.
3. The primary purpose of a hydrocolloid dressing (e.g., DuoDERM) is to:
A) Debride necrotic tissue enzymatically.
B) Absorb large amounts of exudate from heavily draining wounds.
C) Provide a moist environment for autolytic debridement and healing.
D) Irrigate the wound with a steady stream of solution.
Rationale: Hydrocolloid dressings are occlusive and create a moist, hypoxic environment that
,promotes autolytic debridement (the body's own enzymes break down necrotic tissue) and
facilitates granulation tissue formation.
4. A patient with a venous leg ulcer is being discharged. Which instruction is most critical for
the nurse to include in the teaching plan?
A) "Soak your legs in a warm bath twice a day."
B) "Apply compression stockings as prescribed."
C) "Keep your legs in a dependent position."
D) "Use a heating pad on a low setting to improve circulation."
Rationale: The underlying pathophysiology of venous ulcers is venous hypertension and
incompetence. Compression therapy is the cornerstone of treatment, as it counteracts the
venous pressure and promotes venous return.
5. Which finding is the earliest indicator of a potential pressure injury?
A) A blister filled with clear fluid.
B) Non-blanchable erythema of intact skin.
C) A shallow open ulcer with a red-pink wound bed.
D) A localized area of macerated skin.
Rationale: Non-blanchable erythema (Stage 1) indicates that capillary blood flow is
compromised to the point where redness does not disappear when pressure is applied. This is
the earliest visual sign of tissue damage.
6. When irrigating a wound, the nurse should:
A) Use a syringe with a 19-gauge needle to generate safe, effective pressure.
B) Cleanse from the most contaminated area to the least contaminated area.
C) Use sterile saline that has been opened and at room temperature for 48 hours.
D) Hold the syringe 10-12 inches from the wound bed.
Rationale: A 19-gauge needle (or angiocath) with a 35-65 mL syringe generates approximately 8
psi of pressure, which is effective for cleansing without damaging granulation tissue or driving
bacteria into the wound.
7. A patient has a wound with black, leathery eschar. What is the correct wound stage?
A) Stage 2
B) Stage 3
C) Stage 4
D) Unstageable
Rationale: The wound is unstageable because the eschar (necrotic tissue) obscures the true
depth of the wound. The eschar must be debrided before an accurate stage can be determined.
,8. The nurse is calculating a patient's Braden Scale score. Which subscale assesses the degree
of physical activity?
A) Sensory Perception
B) Moisture
C) Activity
D) Mobility
Rationale: The "Activity" subscale of the Braden Scale assesses the degree of physical activity
(e.g., walks frequently, chairfast, bedfast). "Mobility" assesses the ability to change and control
body position.
9. Which type of dressing would be most appropriate for a clean, granulating wound with
minimal exudate?
A) Alginate
B) Transparent film
C) Foam
D) Collagen
Rationale: Transparent film dressings are semi-permeable, maintain a moist environment, and
are ideal for protecting partial-thickness wounds or wounds with minimal exudate. They also
allow for visualization of the wound.
10. Maceration of the periwound skin is caused by:
A) Excessive dryness.
B) Prolonged exposure to moisture.
C) Friction from coarse sheets.
D) Shearing force during repositioning.
Rationale: Maceration is the softening and breaking down of skin due to prolonged exposure to
moisture, such as wound exudate or urine. It makes the skin more susceptible to breakdown
and infection.
Activity & Immobility
11. A patient on prolonged bed rest is at greatest risk for which complication?
A) Pressure Injuries
B) Orthostatic Hypotension
C) Deep Vein Thrombosis (DVT)
D) All of the above
Rationale: While all are significant risks of immobility, pressure injuries are a direct and
extremely common consequence of unrelieved pressure on tissues, especially over bony
prominences.
, 12. The nurse is preparing to log-roll a patient who has undergone spinal surgery. The primary
reason for this maneuver is to:
A) Promote patient comfort.
B) Maintain alignment of the spine.
C) Facilitate easier repositioning for the nurse.
D) Assess for skin breakdown.
Rationale: Log-rolling technique moves the patient's body as a single unit, preventing twisting
or flexion of the spine, which is critical to prevent injury after spinal surgery or with a spinal cord
injury.
13. A patient with a left-sided weakness is being taught to use a cane. The nurse should
instruct the patient to:
A) Hold the cane in the left hand.
B) Hold the cane in the right hand.
C) Hold the cane in whichever hand is more comfortable.
D) Use two canes for maximum support.
Rationale: The cane should be held in the strong (unaffected) hand. This provides a wider base
of support and allows the patient to shift weight onto the cane and the strong leg when moving
the weak leg forward.
14. Which finding is a clinical manifestation of a Deep Vein Thrombosis (DVT)?
A) Pallor and coolness of the affected limb.
B) Unilateral edema, warmth, and redness.
C) Bounding pedal pulse.
D) Muscle spasms.
Rationale: DVT is characterized by inflammation and obstruction of venous flow, leading to the
classic signs of unilateral edema, warmth, redness (erythema), and pain in the affected limb.
15. To prevent foot drop in a patient who is immobilized, the nurse should:
A) Use a trochanter roll.
B) Place a pillow under the knees.
C) Use a footboard or high-top tennis shoes.
D) Encourage quadriceps setting exercises.
Rationale: A footboard or high-top shoes maintain dorsiflexion, preventing the plantar flexion
that leads to the permanent contracture known as foot drop.
16. The nurse is assessing for orthostatic hypotension. A positive finding is a drop in systolic
blood pressure of:*
A) 5 mm Hg
B) 10 mm Hg
ACTIVITY/IMMOBILITY, ASSESSMENT TECHNIQUES,
HEAD/NECK/NEURO ASSESSMENT & RESPIRATORY)
2025/2026 COMPLETE QUESTIONS AND DETAILED
ANSWERS WITH RATIONALES || 100% GUARANTEED
PASS <LATEST VERSION>
Skin Integrity & Wound Care
1. A nurse is assessing a patient's pressure injury. The wound presents as a full-thickness skin
loss with exposed adipose tissue, but no bone, tendon, or muscle is visible. How should the
nurse stage this injury?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
Rationale: Stage 3 pressure injuries involve full-thickness skin loss with damage or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia. Bone,
tendon, and muscle are not exposed.
2. When documenting the characteristics of a wound, the nurse notes a thick, yellow, foul-
smelling drainage. What term should the nurse use?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent
Rationale: Purulent exudate is thick, often yellow, green, or brown, and indicates an infectious
process. The foul smell is a classic sign of infection.
3. The primary purpose of a hydrocolloid dressing (e.g., DuoDERM) is to:
A) Debride necrotic tissue enzymatically.
B) Absorb large amounts of exudate from heavily draining wounds.
C) Provide a moist environment for autolytic debridement and healing.
D) Irrigate the wound with a steady stream of solution.
Rationale: Hydrocolloid dressings are occlusive and create a moist, hypoxic environment that
,promotes autolytic debridement (the body's own enzymes break down necrotic tissue) and
facilitates granulation tissue formation.
4. A patient with a venous leg ulcer is being discharged. Which instruction is most critical for
the nurse to include in the teaching plan?
A) "Soak your legs in a warm bath twice a day."
B) "Apply compression stockings as prescribed."
C) "Keep your legs in a dependent position."
D) "Use a heating pad on a low setting to improve circulation."
Rationale: The underlying pathophysiology of venous ulcers is venous hypertension and
incompetence. Compression therapy is the cornerstone of treatment, as it counteracts the
venous pressure and promotes venous return.
5. Which finding is the earliest indicator of a potential pressure injury?
A) A blister filled with clear fluid.
B) Non-blanchable erythema of intact skin.
C) A shallow open ulcer with a red-pink wound bed.
D) A localized area of macerated skin.
Rationale: Non-blanchable erythema (Stage 1) indicates that capillary blood flow is
compromised to the point where redness does not disappear when pressure is applied. This is
the earliest visual sign of tissue damage.
6. When irrigating a wound, the nurse should:
A) Use a syringe with a 19-gauge needle to generate safe, effective pressure.
B) Cleanse from the most contaminated area to the least contaminated area.
C) Use sterile saline that has been opened and at room temperature for 48 hours.
D) Hold the syringe 10-12 inches from the wound bed.
Rationale: A 19-gauge needle (or angiocath) with a 35-65 mL syringe generates approximately 8
psi of pressure, which is effective for cleansing without damaging granulation tissue or driving
bacteria into the wound.
7. A patient has a wound with black, leathery eschar. What is the correct wound stage?
A) Stage 2
B) Stage 3
C) Stage 4
D) Unstageable
Rationale: The wound is unstageable because the eschar (necrotic tissue) obscures the true
depth of the wound. The eschar must be debrided before an accurate stage can be determined.
,8. The nurse is calculating a patient's Braden Scale score. Which subscale assesses the degree
of physical activity?
A) Sensory Perception
B) Moisture
C) Activity
D) Mobility
Rationale: The "Activity" subscale of the Braden Scale assesses the degree of physical activity
(e.g., walks frequently, chairfast, bedfast). "Mobility" assesses the ability to change and control
body position.
9. Which type of dressing would be most appropriate for a clean, granulating wound with
minimal exudate?
A) Alginate
B) Transparent film
C) Foam
D) Collagen
Rationale: Transparent film dressings are semi-permeable, maintain a moist environment, and
are ideal for protecting partial-thickness wounds or wounds with minimal exudate. They also
allow for visualization of the wound.
10. Maceration of the periwound skin is caused by:
A) Excessive dryness.
B) Prolonged exposure to moisture.
C) Friction from coarse sheets.
D) Shearing force during repositioning.
Rationale: Maceration is the softening and breaking down of skin due to prolonged exposure to
moisture, such as wound exudate or urine. It makes the skin more susceptible to breakdown
and infection.
Activity & Immobility
11. A patient on prolonged bed rest is at greatest risk for which complication?
A) Pressure Injuries
B) Orthostatic Hypotension
C) Deep Vein Thrombosis (DVT)
D) All of the above
Rationale: While all are significant risks of immobility, pressure injuries are a direct and
extremely common consequence of unrelieved pressure on tissues, especially over bony
prominences.
, 12. The nurse is preparing to log-roll a patient who has undergone spinal surgery. The primary
reason for this maneuver is to:
A) Promote patient comfort.
B) Maintain alignment of the spine.
C) Facilitate easier repositioning for the nurse.
D) Assess for skin breakdown.
Rationale: Log-rolling technique moves the patient's body as a single unit, preventing twisting
or flexion of the spine, which is critical to prevent injury after spinal surgery or with a spinal cord
injury.
13. A patient with a left-sided weakness is being taught to use a cane. The nurse should
instruct the patient to:
A) Hold the cane in the left hand.
B) Hold the cane in the right hand.
C) Hold the cane in whichever hand is more comfortable.
D) Use two canes for maximum support.
Rationale: The cane should be held in the strong (unaffected) hand. This provides a wider base
of support and allows the patient to shift weight onto the cane and the strong leg when moving
the weak leg forward.
14. Which finding is a clinical manifestation of a Deep Vein Thrombosis (DVT)?
A) Pallor and coolness of the affected limb.
B) Unilateral edema, warmth, and redness.
C) Bounding pedal pulse.
D) Muscle spasms.
Rationale: DVT is characterized by inflammation and obstruction of venous flow, leading to the
classic signs of unilateral edema, warmth, redness (erythema), and pain in the affected limb.
15. To prevent foot drop in a patient who is immobilized, the nurse should:
A) Use a trochanter roll.
B) Place a pillow under the knees.
C) Use a footboard or high-top tennis shoes.
D) Encourage quadriceps setting exercises.
Rationale: A footboard or high-top shoes maintain dorsiflexion, preventing the plantar flexion
that leads to the permanent contracture known as foot drop.
16. The nurse is assessing for orthostatic hypotension. A positive finding is a drop in systolic
blood pressure of:*
A) 5 mm Hg
B) 10 mm Hg
