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Studied by 143 peopleNoteStudied by 10 peopleNoteStudied by 1 personNoteStudied by 23 peopleNoteStudied by 3 peopleNoteStudied by 91 peopleTissue Integrity Quizzes
A nurse assesses a pressure injury with full-thickness skin loss and visible adipose tissue. No bone, muscle, or tendon is exposed. What stage is this pressure injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
What is the most important nursing intervention for preventing pressure injuries in at-risk patients?
A. Massage reddened areas to promote circulation.
B. Reposition the patient every 2 hours.
C. Keep the patient in a high Fowler’s position.
D. Apply a tight dressing to high-risk areas.
A nurse notices that a patient's surgical incision has separated, revealing underlying tissue but not organs. What complication is this?
A. Evisceration
B. Dehiscence
C. Fistula formation
D. Infection
Which of the following is the best dietary choice to promote wound healing?
A. High-protein diet with vitamin C and zinc
B. Low-fat diet with high carbohydrates
C. High-sodium diet with fluids
D. Vegan diet with only plant-based proteins
A nurse assesses a patient with a non-blanchable, intact red area over the sacrum. What is the appropriate documentation?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Suspected deep tissue injury
D. Unstageable pressure injury
Which of the following patients is at highest risk for developing a pressure injury?
A. A 22-year-old with a fractured femur
B. A 45-year-old with a history of smoking
C. A 68-year-old with paraplegia and incontinence
D. A 30-year-old with a rash from an allergic reaction
Which nursing action is most appropriate for preventing pressure injuries in an immobile patient?
A. Elevating the head of the bed to 90 degrees
B. Positioning the patient on a pressure-reducing surface
C. Applying lotion only once per day
D. Allowing the patient to sit in a wheelchair for extended periods
A nurse is caring for a patient with a stage 4 pressure injury with exposed bone. What is the priority nursing intervention?
A. Encourage repositioning every 4 hours
B. Apply heat therapy
C. Maintain strict aseptic wound care
D. Massage surrounding skin to improve circulation
A nurse is reviewing the Braden Scale with a nursing student. Which score represents high risk for pressure injuries?
A. 20
B. 17
C. 12
D. 9
Which statement by a UAP (CNA) requires intervention?
A. “I will help the patient reposition every 2 hours.”
B. “I will apply a prescription dressing to the wound.”
C. “I will report any new redness to the nurse.”
D. “I will assist the patient with hygiene and incontinence care.”
Select-All-That-Apply (SATA) Questions
The nurse is teaching a patient about pressure injury prevention. Which statements indicate understanding? (Select all that apply.)
A. “I should reposition myself every hour when sitting in a chair.”
B. “I will increase my protein intake to promote skin healing.”
C. “Applying alcohol-based lotions will help prevent skin breakdown.”
D. “I should keep my skin clean and dry.”
E. “Using a donut cushion will help prevent pressure injuries.”
A nurse is caring for a post-operative patient at risk for dehiscence. What actions should the nurse take? (Select all that apply.)
A. Encourage the patient to splint the incision when coughing.
B. Keep the patient in a low Fowler’s position.
C. Apply a tight abdominal binder at all times.
D. Encourage adequate protein intake.
E. Monitor the wound for signs of infection.
Which of the following are systemic factors affecting wound healing? (Select all that apply.)
A. Diabetes
B. Poor circulation
C. Low hemoglobin
D. Excessive moisture
E. Smoking
The nurse is educating a group of CNAs on early signs of a pressure injury. Which should they report to the nurse? (Select all that apply.)
A. Non-blanchable redness
B. Open wounds with drainage
C. Skin that is warm to touch
D. Complaints of localized pain
E. Presence of tunneling or slough
Which of the following increase the risk for pressure injuries? (Select all that apply.)
A. Immobility
B. Poor nutrition
C. Peripheral neuropathy
D. Smoking
E. Frequent ambulation
Which of the following are local factors affecting wound healing? (Select all that apply.)
A. Pressure
B. Infection
C. Smoking
D. Necrosis
E. Tissue perfusion
A patient has a suspected deep tissue injury. What is the characteristic appearance of this injury?
A. Non-blanchable deep red, purple, or maroon discoloration
B. Open wound with yellow slough
C. Partial-thickness loss with exposed dermis
D. Full-thickness skin loss with exposed adipose tissue
A patient with a stage 3 pressure injury has developed a fever and purulent drainage. What is the priority nursing intervention?
A. Obtain a wound culture
B. Apply a dry dressing
C. Encourage repositioning every 4 hours
D. Assess for signs of dehydration
What is the primary function of the epidermis?
A. Provides insulation
B. Contains blood vessels and nerves
C. Produces sebum for lubrication
D. Acts as a protective barrier
The nurse is teaching a patient with diabetes about foot care. Which statement indicates the need for further teaching?
A. “I will inspect my feet daily.”
B. “I will soak my feet in warm water every night.”
C. “I will wear well-fitting shoes.”
D. “I will keep my feet clean and dry.”
A nurse is caring for a patient with a wound that has been open for several weeks and shows no signs of healing. What type of wound is this classified as?
A. Acute
B. Chronic
C. Intentional
D. Closed
The nurse is reviewing documentation of a patient’s wound and notes the presence of tunneling. What does this indicate?
A. The wound has healed significantly
B. The wound is worsening and extending into deeper tissues
C. There is no need for further interventions
D. The wound is in the proliferation phase of healing
Which of the following interventions is most effective in preventing pressure injuries in a high-risk patient?
A. Applying a heating pad to the sacral area
B. Keeping the head of the bed elevated at 90 degrees
C. Repositioning the patient every 2 hours
D. Encouraging the patient to drink more fluids
A nurse is caring for a patient with a pressure injury that has exposed bone and tunneling. How should this wound be staged?
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable
A nurse notes serosanguineous drainage from a surgical wound. What does this indicate?
A. Active infection
B. Presence of necrotic tissue
C. Expected wound healing process
D. The need for immediate wound debridement
Which of the following factors can delay wound healing? (Select all that apply.)
A. Poor nutrition
B. Smoking
C. Well-controlled diabetes
D. Obesity
E. Increased protein intake
A patient with a Braden Scale score of 10 is at what level of risk for pressure injuries?
A. Low risk
B. Moderate risk
C. High risk
D. Very high risk
The nurse is caring for a patient with perineal dermatitis due to incontinence. What intervention should be included in the plan of care? (Select all that apply.)
A. Use a moisture barrier cream
B. Increase the patient’s fluid intake
C. Frequently change soiled linens
D. Use alcohol-based wipes for cleansing
E. Keep the skin clean and dry
A nurse assesses a patient’s wound and notes yellow slough covering the wound bed. How should this wound be classified?
A. Stage 2 pressure injury
B. Unstageable pressure injury
C. Stage 3 pressure injury
D. Suspected deep tissue injury
The nurse is teaching a group of nursing students about wound dehiscence. Which statement indicates further teaching is needed?
A. “Dehiscence is the partial or complete separation of wound edges.”
B. “Patients at risk should avoid excessive coughing and straining.”
C. “Once dehiscence occurs, the wound must be packed with dry gauze.”
D. “Wounds may need reinforcement with additional dressings if dehiscence occurs.”
Which of the following are intrinsic factors that contribute to pressure injury development? (Select all that apply.)
A. Malnutrition
B. Moisture
C. Impaired mobility
D. Chronic illnesses
E. Poor positioning
A patient with peripheral artery disease (PAD) has a wound on their lower extremity. Which statement by the nurse is correct about wound healing in PAD patients?
A. “Your wound will heal normally without complications.”
B. “We will need to ensure adequate blood circulation to promote healing.”
C. “You should elevate your legs to increase circulation to the wound.”
D. “Antibiotics are the only necessary treatment for your wound.”
A nurse is educating a patient on proper wound care. Which statement by the patient indicates understanding?
A. “I will keep my wound covered and moist to promote healing.”
B. “I will allow my wound to air dry to form a scab.”
C. “I will use alcohol to clean my wound daily.”
D. “I should scrub the wound to remove any debris.”
A patient has an unstageable pressure injury on their sacrum. What is the defining characteristic of this wound?
A. Presence of tunneling
B. Thick, yellow slough or eschar covering the wound bed
C. Open wound with visible adipose tissue
D. Non-blanchable redness
Which intervention is most appropriate for a patient at risk for dehiscence following abdominal surgery?
A. Applying a heating pad to the incision site
B. Encouraging coughing without splinting
C. Encouraging ambulation without abdominal support
D. Teaching the patient to splint the incision while coughing or moving
C - Stage 3 involves full-thickness skin loss with visible adipose tissue. Bone, tendon, or muscle is not exposed.
B - Frequent repositioning prevents prolonged pressure on one area, reducing the risk of pressure injuries.
B - Dehiscence is the partial or complete separation of wound edges, commonly occurring in surgical wounds.
A - Protein, vitamin C, and zinc are essential for tissue repair and wound healing.
A - Non-blanchable redness of intact skin is characteristic of a Stage 1 pressure injury.
C - Patients with paraplegia and incontinence are at high risk due to lack of mobility and excessive moisture.
B - Pressure-reducing surfaces redistribute pressure, lowering the risk of skin breakdown.
C - A Stage 4 pressure injury has a high risk for infection and osteomyelitis, requiring strict aseptic wound care.
C - A Braden Scale score of 12 indicates a high risk for pressure injury development.
B - UAPs cannot apply prescription dressings; this is the responsibility of the RN or LPN.
A, B, D - Repositioning, good nutrition, and keeping skin dry help prevent pressure injuries.
A, B, D, E - Splinting incisions, maintaining low Fowler’s, good nutrition, and monitoring for infection help prevent dehiscence.
A, B, C, E - Diabetes, circulation issues, low hemoglobin, and smoking impair wound healing.
A, C, D - Redness, warmth, and localized pain are early indicators of pressure injury development.
A, B, C, D - Immobility, poor nutrition, neuropathy, and smoking all contribute to pressure injury risk.
A, B, D - Pressure, infection, and necrosis directly affect the wound site, delaying healing.
A - Deep tissue injuries appear deep red, purple, or maroon, signaling damage beneath intact skin.
A - Fever and purulent drainage indicate infection, requiring a wound culture.
D - The epidermis acts as a protective barrier against infections and injury.
B - Soaking feet increases the risk of maceration and infection, which should be avoided in diabetic patients.
B - Chronic wounds fail to progress through the normal healing process within the expected timeframe.
B - Tunneling wounds extend into deeper tissues, increasing the risk of complications.
C - Repositioning every 2 hours is key in preventing pressure injuries.
C - Stage 4 pressure injuries involve exposed bone, tendon, or muscle.
C - Serosanguineous drainage is normal in the early healing phase of wounds.
A, B, D - Poor nutrition, smoking, and obesity all delay wound healing.
D - A Braden score of ≤9 indicates very high risk for pressure injuries.
A, C, E - Barrier creams, frequent linen changes, and keeping the skin dry prevent moisture-associated damage.
B - Unstageable pressure injuries have slough or eschar covering the wound bed, preventing proper staging.
C - Packing dehisced wounds with dry gauze is incorrect; wounds should be kept moist.
A, C, D - Malnutrition, impaired mobility, and chronic illnesses are intrinsic factors leading to pressure injuries.
B - Adequate circulation is critical for wound healing in patients with PAD.
A - Moist wound healing promotes faster recovery and less scarring.
B - Unstageable wounds are covered with thick slough or eschar, requiring removal to determine depth.
D - Splinting the incision while coughing/moving reduces stress and prevents dehiscence.
A nurse is performing a skin assessment on a patient with suspected jaundice. Which area should the nurse assess to confirm the finding?
a) Palms of hands
b) Sclera of the eyes
c) Nail beds
d) ScalpA patient has a wound with purulent drainage. Which characteristic should the nurse expect?
a) Clear and watery fluid
b) Yellow or green thick fluid with an odor
c) Pink-tinged drainage
d) Bright red bloodWhen assessing a patient with dark skin for cyanosis, the nurse should examine which area?
a) Lips and nail beds
b) Abdomen
c) Palms and soles of feet
d) Behind the earsWhich of the following primary lesions is characterized by fluid-filled vesicles?
a) Macule
b) Papule
c) Bulla
d) PlaqueThe nurse is educating a patient with psoriasis. Which statement by the patient indicates the need for further teaching?
a) "I should avoid scratching my lesions."
b) "I can use oatmeal baths to soothe my skin."
c) "I should stay away from any triggers like stress."
d) "I should take antibiotics to treat my condition."A nurse is caring for a patient with a stage III pressure ulcer. What characteristic is expected?
a) Partial-thickness loss of dermis
b) Full-thickness tissue loss with visible bone or tendon
c) Full-thickness skin loss with subcutaneous tissue exposure
d) Intact skin with non-blanchable rednessA patient presents with a red, itchy rash caused by exposure to poison ivy. This condition is classified as:
a) Impetigo
b) Contact dermatitis
c) Psoriasis
d) CellulitisWhich diagnostic test is used to identify fungal infections of the skin?
a) Biopsy
b) Patch testing
c) Wood's light examination
d) Culture and sensitivityThe nurse notes clubbing of the patient’s fingernails. This may be indicative of:
a) Anemia
b) Chronic hypoxia
c) Dehydration
d) Liver diseaseA patient with impetigo asks how to prevent spreading the infection. Which response is correct?
a) "You should avoid washing the affected area frequently."
b) "You should cover the lesions and wash hands frequently."
c) "You should apply antibiotic cream only if it becomes painful."
d) "You should avoid all forms of topical treatment."
Select All That Apply (SATA)
A nurse is teaching a patient about risk factors for pressure ulcers. Which of the following are considered risk factors? (Select all that apply.)
a) Immobility
b) Poor nutrition
c) Increased sensory perception
d) Moisture exposure
e) Advanced age
When inspecting a wound, which findings would indicate signs of infection? (Select all that apply.)
a) Increased warmth around the wound
b) Clear, serous drainage
c) Pus or foul-smelling drainage
d) Redness and swelling
e) Decreased pain in the wound area
A nurse is assessing a patient’s skin for dehydration. Which findings would support this diagnosis? (Select all that apply.)
a) Tenting of the skin
b) Diaphoresis
c) Dry mucous membranes
d) Increased skin elasticity
e) Cracked lips
A nurse is educating a patient about factors that contribute to delayed wound healing. Which statements should be included? (Select all that apply.)
a) "Smoking can slow down wound healing."
b) "Diabetes can increase the risk of wound healing complications."
c) "Good hydration can negatively impact wound healing."
d) "A high-protein diet is beneficial for wound healing."
e) "Steroid use may impair wound healing."
When assessing a dark-skinned patient for pallor, the nurse should assess which areas? (Select all that apply.)
a) Lips
b) Palms of hands
c) Nail beds
d) Conjunctiva
e) Abdomen
A nurse is preparing to assess a patient’s nail health. Which findings would be considered abnormal? (Select all that apply.)
a) Beau’s lines
b) Clubbing
c) Pink and transparent nails
d) Spoon nails (koilonychia)
e) Thick, yellow nails
The nurse is assessing a patient’s hair and scalp. Which findings indicate a potential concern? (Select all that apply.)
a) Excessive hair thinning
b) Red, pustular eruptions on the scalp
c) Even hair distribution
d) Dry, brittle hair
e) Lice eggs (nits) in hair strands
Which of the following interventions are important for preventing pressure ulcers in at-risk patients? (Select all that apply.)
a) Repositioning the patient every 2 hours
b) Keeping the skin clean and dry
c) Massaging bony prominences to stimulate circulation
d) Using pressure-relieving devices
e) Encouraging a high-protein diet
A nurse is documenting wound characteristics. What should be included in the documentation? (Select all that apply.)
a) Wound size (length, width, depth)
b) Presence of drainage and its characteristics
c) Patient’s pain level
d) Type of dressing applied
e) The patient’s vital signs
A nurse is educating a patient about proper wound care at home. Which statements should be included? (Select all that apply.)
a) "Wash your hands before and after changing the dressing."
b) "Monitor for increased redness, swelling, or foul-smelling drainage."
c) "Use hydrogen peroxide daily to clean the wound."
d) "Keep the wound covered with a clean dressing."
e) "Avoid using antibiotic ointments as they delay healing."
Which conditions can cause petechiae? (Select all that apply.)
a) Blood clotting disorders
b) Trauma to the skin
c) Liver disease
d) Dehydration
e) Anemia
When performing a capillary refill test, the nurse notes a refill time of 5 seconds. What does this indicate? (Select all that apply.)
a) Normal circulation
b) Possible dehydration
c) Impaired perfusion
d) Oxygenation issues
e) No concern if the patient is elderly
A patient with shingles presents with a rash following a dermatomal distribution. What other findings may be present? (Select all that apply.)
a) Unilateral vesicles
b) Severe pain or burning
c) Honey-colored crusts
d) Itching
e) Systemic fever
The nurse is caring for a patient with edema. Which assessment findings would confirm the presence of pitting edema? (Select all that apply.)
a) Indentation remains after pressing the skin
b) Skin appears shiny and tight
c) Skin returns to normal immediately after pressure is released
d) A grading scale is used to determine severity
e) Capillary refill is delayed
A patient asks how to prevent fungal infections on the skin. What advice should the nurse give? (Select all that apply.)
a) Keep skin clean and dry
b) Avoid walking barefoot in public showers
c) Share towels and personal hygiene items
d) Wear loose-fitting, breathable clothing
e) Apply antifungal powder as needed
1. B
2. B
3. A
4. C
5. D
6. C
7. B
8. C
9. B
10. B
11. A, B, D, E
12. A, C, D
13. A, C, E
14. A, B, D, E
15. A, B, C, D
16. A, B, D, E
17. A, B, D, E
18. A, B, D, E
19. A, B, C, D
20. A, B, D
21. A, B, C
22. B, C, D
23. A, B, D, E
24. A, B, D
25. A, B, D, E
NoteStudied by 143 peopleNoteStudied by 10 peopleNoteStudied by 1 personNoteStudied by 23 peopleNoteStudied by 3 peopleNoteStudied by 91 people