NCLEX Skin Integrity and Wound Care Practice Exam

NCLEX Skin Integrity and Wound Care Practice Exam

What is Skin Integrity and Wound Care?

Skin integrity is the foundation of patient safety and comfort. The skin is the body’s largest organ and serves as a protective barrier against infection, injury, and fluid loss. When skin is compromised—whether from pressure injuries, surgical wounds, diabetic ulcers, burns, or device-related friction—the risk of complications such as infection, pain, delayed healing, and even sepsis increases significantly.

Wound care in nursing practice involves the assessment, prevention, and management of skin breakdown. This includes choosing the right dressings, implementing pressure-relief strategies, maintaining proper moisture balance, providing nutritional support, and educating patients about prevention and self-care. In the NCLEX, skin integrity and wound care are considered high-priority areas because they directly relate to patient safety and quality outcomes.

About This Exam

The Skin Integrity and Wound Care Practice Exam is designed for nursing students and graduates preparing for the NCLEX-RN® or NCLEX-PN®. This exam mirrors the style and depth of actual NCLEX questions, covering everything from Braden Scale assessment to negative pressure wound therapy (NPWT), pressure injury staging, burn management, and moisture-associated skin damage (MASD).

Each question includes detailed rationales that explain not just the correct answer, but why the other options are incorrect. This method helps test-takers build critical thinking skills and apply knowledge in real-world clinical scenarios. The exam reflects current evidence-based wound care practices (2025 standards), ensuring that learners are fully prepared for both the NCLEX and bedside nursing responsibilities.

Topics Covered in This Exam

This practice exam provides comprehensive coverage of NCLEX-relevant content, including:

• Pressure Injury Prevention & Staging
  • Differentiating Stage 1–4, unstageable, and deep tissue pressure injuries.
  • Risk assessment using the Braden Scale (nutrition, moisture, mobility, activity, friction/shear).
  • Offloading devices (heel suspension boots, specialty beds, low-air-loss surfaces).
• Skin Integrity Risk Factors
  • Effects of immobility, sedation, poor nutrition, moisture, incontinence, and comorbidities.
  • Shear vs friction vs moisture damage.
  • Pediatric and geriatric skin considerations.
• Burns and Wound Management
  • Rule of Nines and Rule of Palms for TBSA estimation.
  • Fluid resuscitation using the Parkland formula.
  • Burn wound care priorities: escharotomy, infection prevention, graft bolsters, pruritus management.
• Wound Cleansing & Debridement
  • Safe irrigation pressure (8–15 psi).
  • Autolytic, enzymatic, mechanical, and sharp debridement.
  • Contraindications: ischemic heel eschar, untreated osteomyelitis.
• Moisture-Associated Skin Damage (MASD)
  • Incontinence-associated dermatitis (IAD).
  • Peristomal MASD and candidiasis management.
  • Intertriginous dermatitis and prevention strategies.
• Specialized Wound Therapies
  • Negative pressure wound therapy (NPWT): indications, contraindications, complications.
  • Hyperbaric oxygen for chronic ischemic wounds.
  • Maggot therapy and enzymatic debridement.
• Chronic Wounds
  • Diabetic foot ulcer classification (Wagner and UT systems).
  • Arterial vs venous ulcers—pain, location, exudate, and management differences.
  • Lymphedema care and cellulitis prevention.
• Surgical & Device-Related Skin Care
  • Incision healing by primary, secondary, tertiary intention.
  • Drain site care and criteria for removal.
  • CPAP/NIV mask-related injuries and securement techniques.
  • Preventing medical adhesive-related skin injury (MARSI).
• Documentation & Patient Education
  • Correct staging, negatives (undermining, tunneling), periwound assessment.
  • Consent and de-identification for wound photography.
  • Teaching patients wound self-care, showering guidance, compression adherence.

Who Can Take This Exam?

This exam is ideal for:

• Nursing students preparing for the NCLEX-RN® or NCLEX-PN®.
• New graduates who want extra practice with wound care scenarios.
• Practicing nurses refreshing their knowledge for clinical competence or continuing education.
• Nursing assistants and allied health staff who want to understand the basics of pressure injury prevention.
• Educators and trainers who want high-quality NCLEX-style content to use in courses or workshops.

Benefits of This Exam

• Boosts NCLEX readiness: Skin integrity questions are common on the NCLEX because they reflect real patient safety issues.
• Strengthens critical thinking: Each rationale explains both correct and incorrect answers.
• Updated for 2025: Content aligns with current wound care guidelines, staging definitions, and clinical practices.
• Comprehensive coverage: From pressure injury staging to burn management, nothing important is left out.
• Real-world application: Prepares you not just for passing the NCLEX, but for day-to-day nursing practice.

Study Tips to Pass the Exam

1. Understand Staging Rules
   Practice differentiating Stage 2 vs skin tears vs IAD vs DTPI. Many NCLEX candidates confuse these—knowing exact definitions is crucial.
2. Link Pathophysiology to Care
   Don’t just memorize; connect why arterial ulcers hurt with elevation or why venous ulcers ooze more. This makes exam questions easier to analyze.
3. Use the Braden Scale Actively
   Learn how each subscale (nutrition, mobility, moisture, friction/shear) impacts prevention interventions.
4. Review Burn Formulas
   Be comfortable calculating fluid resuscitation with the Parkland formula and estimating TBSA.
5. Know Dressing Types
   Match dressing to wound needs: alginate for heavy drainage, hydrogel for dry eschar, foam for moderate exudate, charcoal for odor.
6. Practice Prioritization
   When a wound-related emergency arises (e.g., sudden bright red blood in NPWT canister), prioritize stopping bleeding and notifying provider over routine tasks.
7. Focus on Patient Safety
   Always consider infection prevention, device-related injury prevention, and skin inspection in every scenario.
8. Simulate Testing Conditions
   Take timed quizzes to mimic NCLEX pacing. Review rationales immediately to reinforce learning.

The Skin Integrity and Wound Care Practice Exam is more than just a test prep tool—it is a comprehensive learning resource that strengthens your understanding of wound management, patient safety, and evidence-based nursing practice. By working through these questions and studying the rationales, you’ll not only prepare for the NCLEX but also build the confidence to deliver safe, effective wound care in clinical settings.

Whether you are a student, a graduate, or a practicing nurse, mastering skin integrity and wound care will enhance your professional competence and directly improve patient outcomes.

Sample Questions and Answers

1) Preventing Shear During Repositioning

A bed-bound patient with a Braden score of 12 needs turning. Which action best reduces shear during repositioning?
A. Elevate the head of bed to 45° and pull the patient up by the shoulders
B. Keep the head of bed ≤30° and use a draw sheet to lift, not drag
C. Logroll with one nurse while the other pulls the heels
D. Place the patient in high-Fowler’s to reduce sacral pressure

Correct: B

Explanation:
Shear occurs when underlying tissues slide while skin stays fixed, damaging capillaries over bony prominences (especially sacrum). To minimize shear, keep the HOB at or below ~30° and use a draw sheet (or friction-reducing device) to lift rather than slide the patient. Option A raises the head excessively and involves dragging—both increase shear. Option C mixes safe logrolling with heel pulling, which risks friction injuries and concentrates shear at the heels. Option D (high-Fowler’s) significantly increases sacral shear because the body tends to slide down. The best evidence-aligned routine is low head elevation, lift-don’t-drag technique, and micro-repositioning on pressure-redistributing surfaces.

2) Identifying Moisture-Associated Skin Damage (MASD)

An incontinent patient has a diffuse, irregularly shaped erythematous area over the perineum and buttocks with intact edges, partial-thickness skin loss, and sparing of bony prominence centers. What is the most likely diagnosis?
A. Stage 2 pressure injury
B. Incontinence-associated dermatitis (IAD)
C. Deep tissue pressure injury
D. Candidal intertrigo only

Correct: B

Explanation:
IAD is a type of MASD caused by prolonged exposure to urine/stool, presenting as diffuse, irregular inflammation across the perineal/buttock region. It is often shallow/partial-thickness and may spare the direct center of bony prominences; pressure injuries typically align directly over a prominence, have clearer borders, and are caused by pressure/shear rather than moisture. Stage 2 injuries are localized to pressure/shear zones; DTPI shows persistent, non-blanchable deep discoloration or blood-filled blistering suggestive of underlying tissue damage. Candidal intertrigo can co-exist but is classically in skin folds with satellite lesions. Management of IAD focuses on gentle cleansing, moisture barriers (zinc/Dimethicone), and incontinence management.

3) Pressure Injury Staging—Slough/Eschar Present

A sacral wound has full-thickness tissue loss obscured by tan slough. The wound base is not visible. How should the nurse stage it?
A. Stage 3
B. Stage 4
C. Unstageable pressure injury
D. Deep tissue pressure injury

Correct: C

Explanation:
If slough or eschar obscures the wound bed so that the depth cannot be determined, the correct label is Unstageable until enough nonviable tissue is removed to visualize the base. Stage 3 and 4 require visible depth (Stage 4 includes exposed or directly palpable bone, tendon, or muscle). Deep Tissue Pressure Injury is characterized by persistent non-blanchable deep red/maroon/purple discoloration, not a slough-covered crater. Appropriate steps include debridement (if consistent with overall plan and perfusion), moist wound healing, infection control, pressure redistribution, and nutritional support. Never “reverse stage” when healing; use terms like “improving” or “granulation present.”

4) Dressing Selection—Heavy Exudate

A patient has a venous leg ulcer with copious serous drainage. Which primary dressing is most appropriate initially?
A. Hydrogel sheet
B. Calcium alginate
C. Transparent film
D. Hydrocolloid wafer

Correct: B

Explanation:
Calcium alginate and some foams are designed to manage moderate to heavy exudate, helping maintain moisture balance and reducing periwound maceration. Hydrogels donate moisture—excellent for dry wounds/eschar but poor for copious exudate (Option A). Transparent films and hydrocolloids trap moisture and can worsen maceration in highly exudative wounds (Options C/D). With venous ulcers, pair compression therapy (if arterial supply is adequate) with absorbent dressings. Protect periwound skin with barrier film or zinc paste. Reassess drainage trends; as exudate decreases, step down to less absorptive dressings to support epithelial migration without over-drying.

5) Compression and ABI Safety

Before applying standard 30–40 mmHg compression for a venous ulcer, which ankle–brachial index (ABI) result is generally considered safe for full compression?
A. 0.45
B. 0.65
C. 0.85
D. 1.35

Correct: C

Explanation:
An ABI ≥0.8 is typically considered safe for standard compression (30–40 mmHg). 0.5–0.8 suggests mixed arterial/venous disease; only modified/light compression may be appropriate and requires provider direction. <0.5 indicates severe arterial insufficiency—avoid compression and escalate vascular evaluation. >1.3 suggests non-compressible, calcified vessels (common in diabetes/CKD) and warrants alternate perfusion tests. Compression improves venous return and edema control, crucial in venous ulcer healing. Nurses should also elevate legs, encourage calf-muscle pumping, and educate on adherence. Always document pulses, capillary refill, skin temperature, and symptoms (rest pain, claudication) and coordinate with the prescriber.

6) Negative Pressure Wound Therapy (NPWT) Contraindication

Which situation is a contraindication to initiating NPWT?
A. Granulating surgical wound with moderate exudate
B. Wound with dry, stable eschar on the heel and poor perfusion
C. Post-debridement traumatic wound with clean base
D. Diabetic foot ulcer with well-protected tendon and adequate perfusion

Correct: B

Explanation:
NPWT (VAC therapy) promotes granulation and removes exudate but is contraindicated when there is dry, stable eschar with poor perfusion (especially heels), untreated osteomyelitis, malignancy in the wound, exposed vital structures without protection, or uncontrolled bleeding. Option A and C are common, appropriate indications when the base is clean and bleeding controlled. Option D can be used when critical structures are properly covered and vascular supply is adequate. In ischemic heels with stable eschar, the eschar serves as the body’s protective cover; avoid debriding or applying NPWT until perfusion is clarified and the plan is set by the provider.

7) Recognizing Deep Tissue Pressure Injury (DTPI)

An immobile patient has a persistent, non-blanchable, deep maroon area over the trochanter after a long transport. Skin is intact. What’s the best nursing action?
A. Massage the area to restore blood flow
B. Document DTPI, offload and monitor closely
C. Cover with hydrocolloid and sit the patient upright
D. Cleanse with antiseptic and debride the surface

Correct: B

Explanation:
DTPI presents as persistent non-blanchable deep red/maroon/purple discoloration due to underlying tissue damage; the skin may be intact. Do not massage pressure injuries—it can worsen damage. Offload pressure immediately with support surfaces, repositioning, and a 30-degree lateral tilt. Hydrocolloids may trap heat/moisture and do not address the causative pressure; sitting upright increases pressure and shear. There’s nothing to debride on intact skin; antiseptics can harm viable tissue. Reassess frequently, protect with soft silicone dressings if appropriate, optimize perfusion, hydration, and nutrition, and escalate if the area rapidly evolves (possible conversion to open injury).

8) Wound Cleansing and Culture Technique

A chronic ulcer shows new malodor and increased drainage. The provider orders a swab culture. Which technique is best?
A. Swab any surface exudate before cleaning
B. Cleanse with normal saline, debride loose slough, then use the Levine technique on viable tissue
C. Apply povidone-iodine liberally and swab the brown area
D. Swab the undermined edge only, without cleansing

Correct: B

Explanation:
For the most clinically relevant swab, cleanse the wound with normal saline to remove contaminants, gently debride loose slough if within scope, then use the Levine technique: press and rotate the swab over a 1 cm² area of viable tissue with enough pressure to express fluid from the base (usually ~5 seconds). This improves detection of organisms truly present in tissue rather than superficial contaminants. Swabbing before cleansing or only undermined edges yields misleading results. Routine antiseptics (e.g., povidone-iodine) can distort cultures and injure healthy cells; selective antimicrobials are used when indicated, not before culture collection.

9) Nutrition for Pressure Injury Healing

Which plan best reflects protein needs for an adult with a stage 3 pressure injury and no contraindications?
A. 0.8 g/kg/day protein, liberal fluids, no supplements
B. 1.25–1.5 g/kg/day protein plus calories, vitamins/minerals as indicated
C. High-fat ketogenic diet to spare protein breakdown
D. Vitamin C and zinc alone without assessing intake

Correct: B

Explanation:
For most adults with pressure injuries (absent renal/other contraindications), recommended protein intake is ~1.25–1.5 g/kg/day, alongside adequate calories and fluids. This supports collagen synthesis, immune function, and granulation. Option A (0.8 g/kg) is typical maintenance, not healing. Option C is not standard for wound healing and may reduce necessary carbohydrate for fibroblast activity. Vitamins should not be given blindly; vitamin C, zinc, and others are considered if deficiencies or increased demands are suspected. A dietitian referral is appropriate. Monitor weight trends, wound progress, edema, and labs (trend prealbumin in context; albumin/CRP are influenced by inflammation).

10) Heels Offloading

Which is the best nursing measure to protect the heels in a high-risk patient?
A. Place a donut-shaped ring under each heel
B. Float heels completely by placing pillows under the calves
C. Wrap heels with elastic bandages for padding
D. Keep heels flat on the mattress but apply a thick ointment

Correct: B

Explanation:
Floating the heels—positioning pillows under the calves so heels are completely off the surface—is the preferred prevention technique. Donut rings concentrate pressure at the edges and can worsen ischemia. Elastic bandages are not designed for offloading and may impair circulation if too tight. Ointment may protect skin from moisture but does nothing for pressure reduction. For patients with contractures or spasticity, consider heel offloading boots; check alignment and skin every shift. Combine with frequent repositioning and avoidance of bed-sheet wrinkles to reduce friction and shear.

11) Skin Tears—Initial Management

An older adult on chronic steroids sustains a skin tear with a viable skin flap. What’s the best first-line approach?
A. Remove the flap; it’s nonviable
B. Gently approximate the flap to its anatomical position and cover with a soft silicone dressing
C. Paint the area with alcohol to dry the flap before covering
D. Secure with tight adhesive tape directly on fragile skin

Correct: B

Explanation:
For many skin tears, especially in fragile skin, the preferred technique is to gently realign/approximate the viable flap to its original position after cleansing, and cover with a soft silicone contact layer or silicone foam to protect while minimizing trauma at dressing changes. Avoid alcohol, which desiccates and injures tissue. Tight adhesives can cause further tearing; use silicone borders or retention netting. Classify the tear (e.g., ISTAP types), protect periwound with barrier film, and institute prevention (long sleeves, safe transfers, moisturizers, careful tape use, and environmental checks).

12) Hydrocolloid Use—When to Avoid

Which scenario is least appropriate for a hydrocolloid dressing?
A. Shallow, clean Stage 2 sacral injury with light exudate
B. Heel with dry, stable eschar and critical limb ischemia
C. Superficial partial-thickness donor site with scant drainage
D. Superficial friction injury over the trochanter with low exudate

Correct: B

Explanation:
Hydrocolloids promote moist healing in shallow, lightly exudative wounds (Options A/C/D). They occlude and can trap moisture/heat—not appropriate on dry, stable eschar in an ischemic heel (Option B), which is typically left intact and protected unless perfusion improves and the plan changes. Hydrocolloids may also be avoided where infection is suspected, in heavy exudate (risk of maceration), or on fragile periwound skin sensitive to adhesive removal. Always reassess exudate; as drainage or goals change, switch to more suitable dressings.

13) Packing a Tunneling Wound

A wound has a 3-cm tunnel at 2 o’clock. Which action is best?
A. Pack the tunnel tightly to obliterate dead space
B. Lightly fill the tunnel with appropriate packing (e.g., ribbon gauze or alginate), leaving a visible tail
C. Avoid packing; seal the surface with a film dressing
D. Irrigate with hydrogen peroxide and leave open to air

Correct: B

Explanation:
Tunnels and undermining require light, non-occlusive packing to wick exudate and prevent premature surface closure. Over-packing (tight) can cause pressure necrosis and pain. Leaving a retrievable tail prevents retained dressing fragments. The packing choice depends on exudate (e.g., alginate for wetter tunnels; plain ribbon gauze for drier). Film alone (Option C) risks trapping drainage. Hydrogen peroxide (Option D) is cytotoxic and can impede healing. Document the tunnel’s clock position and depth each dressing change; notify provider if the tunnel lengthens, develops abscess signs, or exposes structures.

14) Contact Dermatitis vs. Infection

A new erythematous rash develops beneath the adhesive border of a dressing; the wound bed looks clean with no purulence. The patient reports itching and burning. Best action?
A. Start systemic antibiotics
B. Switch to a non-sensitizing adhesive (e.g., silicone), add skin barrier film, and monitor
C. Increase adhesive tension for a tighter seal
D. Apply topical triple-antibiotic under the adhesive daily

Correct: B

Explanation:
This presentation is consistent with contact dermatitis from adhesive—itching, burning, and erythema localized under the border. The wound itself appears clean. Manage by removing the offending adhesive, switching to silicone-based or non-adherent options, using a protective barrier film, and spacing tape use. Systemic antibiotics are not indicated without infection signs (purulent drainage, warmth, swelling, systemic symptoms). Tightening the seal increases pressure and shear, worsening injury. Routine topical antibiotics raise resistance and sensitization risks; reserve antimicrobials for clear infection or per provider orders.

15) Clean vs. Sterile Technique

For routine dressing changes of a chronic pressure injury at home with healthy granulation, which technique is generally acceptable when supplies are limited and no immunosuppression is present?
A. Strict sterile technique always
B. Clean (medical aseptic) technique with hand hygiene and clean gloves
C. No gloves are necessary
D. Sterile technique only if wound is infected

Correct: B

Explanation:
In many chronic wound care contexts (home health, long-term care) where the wound is stable and the patient is not immunocompromised, clean technique—meticulous hand hygiene, clean gloves, clean instruments, and non-contaminated supplies—has outcomes comparable to sterile technique and is pragmatic. Sterile technique is standard for acute surgical wounds, fresh grafts, invasive procedures, or high-risk hosts. “No gloves” is never appropriate. Infection is not the determinant of aseptic level; rather, the wound type, setting, and host factors drive the choice. Always teach patients/ caregivers proper handwashing, clean field setup, and safe disposal.

16) Repositioning Frequency

For a patient at high risk for pressure injury in an acute care bed, what is the recommended repositioning frequency?
A. Every 8 hours
B. Every 4 hours
C. Every 2 hours (or individualized by risk/support surface)
D. Only when the patient feels discomfort

Correct: C

Explanation:
The general guideline for high-risk immobile patients is repositioning at least every 2 hours in bed. Evidence supports that repositioning frequency may vary depending on support surface (e.g., advanced low-air-loss or fluidized beds may extend intervals safely). Repositioning promotes perfusion, reduces sustained pressure, and prevents tissue ischemia. Every 8 or 4 hours is too infrequent. Waiting for patient discomfort is unsafe because many cannot perceive pressure injury development (e.g., spinal cord injury, sedation, neuropathy). Documentation of turning schedules and use of pillows/foam wedges is essential. Repositioning should also include heels offloading and microshifts to reduce shear.

17) First Aid for Minor Burns

A nurse provides initial care for a superficial partial-thickness scald burn. What is the priority immediate action?
A. Apply butter or oil to soothe
B. Cool with running tap water (not ice) for 20 minutes
C. Cover tightly with cotton wool
D. Break intact blisters to release pressure

Correct: B

Explanation:
For minor burns, the first step is cooling with cool (not ice) running water for about 20 minutes. This reduces tissue damage, pain, and edema. Ice should not be applied because it can cause vasoconstriction and further injury. Butter or oils trap heat and increase infection risk. Cotton wool adheres and fibers can contaminate wounds. Blisters are left intact initially unless they are large, tense, and likely to rupture under sterile conditions. After cooling, gently dry, cover with a non-adherent sterile dressing, assess tetanus immunization, and escalate as needed for larger burns or systemic involvement.

18) Pressure Injury Risk Factors

Which patient is at highest risk for developing pressure injuries?
A. Alert older adult walking with a cane, Braden score 19
B. Post-stroke patient, immobile, incontinent, albumin 2.1 g/dL, Braden score 9
C. Young trauma patient, ambulatory with crutches, Braden score 20
D. Middle-aged diabetic with intact sensation, Braden score 18

Correct: B

Explanation:
The Braden Scale helps predict risk: scores ≤12 = high risk. Patient B has multiple risk factors: immobility, incontinence (moisture), poor nutrition (low albumin), and a score of 9. Patients with higher scores (≥18) are lower risk. Ambulatory or mobile patients rarely develop pressure injuries if nutrition and perfusion are adequate. Diabetes increases risk but not as significantly if sensation is intact and mobility is preserved. This question emphasizes comprehensive risk assessment, not just one factor. Preventive measures include pressure redistribution, moisture management, and nutritional support.

19) Surgical Wound Dehiscence

A patient recovering from abdominal surgery reports sudden “popping” at the incision site with serosanguinous drainage. The wound edges are separating. What should the nurse do first?
A. Reapproximate with adhesive strips
B. Apply sterile saline-soaked dressings and notify the surgeon
C. Leave the wound open to air
D. Reinforce with abdominal binder only

Correct: B

Explanation:
Dehiscence is partial/total separation of wound layers. Immediate action is to cover with sterile saline-moistened gauze to keep exposed tissue moist and protected, then notify the surgeon promptly. Do not attempt closure with adhesive strips—it requires surgical assessment. Leaving open to air risks desiccation and infection. An abdominal binder may reduce strain but is not definitive. If evisceration occurs, keep viscera moist with saline gauze, place the patient supine with knees bent to reduce strain, and prepare for emergency surgery. Prevention includes splinting during coughing, controlling infection, and optimizing nutrition.

20) Shear vs. Friction Example

Which is an example of shear rather than friction?
A. Dragging a patient across sheets causing abrasion
B. Patient sliding down in high-Fowler’s, sacrum tissue layers separating
C. Skin rubbing against a cast edge
D. Abrasion on elbow from rolling against bedrails

Correct: B

Explanation:
Friction = two surfaces rubbing (abrasion, superficial). Shear = deeper injury when skin remains fixed while skeleton moves—leading to stretched blood vessels and ischemia. Sliding down in high-Fowler’s is classic shear, especially over sacrum. Dragging across sheets and rubbing against casts/bedrails (A, C, D) are friction examples. Shear and friction often co-occur, worsening risk. Prevention: limit HOB elevation, use trapeze/draw sheets, maintain smooth linens, apply protective dressings to bony prominences, and use support surfaces.

21) NPWT Pressure Settings

Standard negative pressure wound therapy is typically applied at what continuous pressure (unless otherwise ordered)?
A. 25 mmHg
B. 75 mmHg
C. 125 mmHg
D. 200 mmHg

Correct: C

Explanation:
The most common NPWT setting is -125 mmHg continuous suction, which balances fluid removal and stimulation of granulation tissue. Lower settings (50–80 mmHg) may be ordered for pain-sensitive or compromised tissue. Higher settings (>150–200 mmHg) are rarely used and may increase bleeding risk. Settings should always match provider orders and wound type. Nursing responsibilities include ensuring a proper seal, monitoring canister volume, checking tubing patency, and promptly reporting alarms or sudden bleeding. Dressing changes are typically every 48–72 hours, or more often with heavy drainage or infection. NPWT requires strict infection and perfusion monitoring.

22) Stage 1 Pressure Injury—Skin Assessment

Which finding best describes a Stage 1 pressure injury?
A. Intact skin with non-blanchable erythema over a bony prominence
B. Open blister with partial-thickness dermal loss
C. Full-thickness skin loss with visible adipose tissue
D. Purple intact skin over the heel

Correct: A

Explanation:
Stage 1 is defined as intact skin with non-blanchable erythema (redness does not turn white when pressed). It may feel warmer, cooler, firmer, or softer than surrounding tissue. Option B is Stage 2 (open blister/partial thickness). Option C is Stage 3 (full-thickness with visible adipose). Option D describes a deep tissue pressure injury (DTPI). Early recognition of Stage 1 is critical for prevention; offloading, skin protection, and moisture control can reverse the damage before deeper structures are involved. Documenting blanchability clearly differentiates pressure injuries from reactive hyperemia.

23) Cleansing Agent for Pressure Injuries

What is the preferred cleansing solution for most pressure injuries?
A. Sterile normal saline
B. Betadine solution daily
C. Diluted hydrogen peroxide
D. Tap water only, regardless of wound type

Correct: A

Explanation:
Sterile normal saline is the standard cleanser for most pressure injuries because it is isotonic, non-toxic, and does not damage granulation tissue. Betadine and hydrogen peroxide are cytotoxic to fibroblasts and delay healing; they may be used briefly for heavily contaminated wounds but not routine cleansing. Tap water can be safe in some low-resource, non-sterile chronic wound settings, but sterile saline remains the guideline-based choice, especially in acute care. The technique: irrigate with gentle pressure (30–60 mL syringe with 18–19 gauge catheter), removing debris without driving bacteria deeper.

24) Surgical Dehiscence Risk Factors

Which patient is at highest risk for wound dehiscence?
A. 45-year-old with laparoscopic cholecystectomy, BMI 24, no comorbidities
B. 72-year-old with midline laparotomy, poorly controlled diabetes, and chronic cough
C. 35-year-old cesarean section patient with well-controlled asthma
D. 60-year-old with elective hernia repair, BMI 26, adherent to diet

Correct: B

Explanation:
Dehiscence—separation of a surgical incision—is more likely with older age, poor glycemic control, high intra-abdominal pressure (from cough/obesity), malnutrition, infection, and emergency or long incisions. Option B combines multiple risk factors: age, diabetes, coughing (increases pressure), and midline laparotomy. The others involve fewer risks or better control. Nursing actions: monitor for sudden “popping” sensation, serosanguinous drainage, visible separation, or evisceration. Interventions include splinting incision with a pillow during coughing, optimizing glucose, encouraging protein intake, and reporting early signs promptly.

25) Wound Bed Preparation (TIME framework)

In wound bed preparation, the acronym TIME stands for:
A. Tissue, Infection/Inflammation, Moisture balance, Edge advancement
B. Temperature, Integrity, Moisture, Exudate
C. Tunneling, Ischemia, Medications, Edema
D. Topical, Irrigation, Moisture, Enzymes

Correct: A

Explanation:
The TIME framework guides wound assessment and healing optimization:

• T = Tissue (remove nonviable tissue, preserve healthy tissue)
• I = Infection/Inflammation (reduce bioburden, control infection)
• M = Moisture balance (avoid desiccation or maceration)
• E = Edge advancement (stimulate epithelial migration, address stalled edges).
  Options B–D are distractors mixing wound concepts but not the accepted model. Applying TIME ensures a structured approach for chronic wounds, integrating debridement, antimicrobial stewardship, moisture dressings, and adjunctive therapies like NPWT or growth factors.

26) Autolytic Debridement

Which dressing best promotes autolytic debridement of yellow slough?
A. Dry gauze
B. Hydrocolloid or hydrogel
C. Tightly packed cotton balls
D. Iodine-soaked gauze

Correct: B

Explanation:
Autolytic debridement leverages the body’s own enzymes and moisture to liquefy necrotic tissue. Hydrocolloids and hydrogels create a moist environment, facilitating this gentle process. It is selective, painless, and often used for patients unable to tolerate sharp debridement. Dry gauze desiccates and sticks to tissue, causing trauma. Cotton balls are not wound dressings and pose infection risk. Iodine gauze may have antimicrobial effect but does not sustain autolysis and may impair granulation. Autolysis is slower than surgical/sharp methods but valuable in stable, non-infected wounds and can be combined with other strategies.

27) Burn Depth Assessment

A burn is red, moist, very painful, with blisters and blanching present. This is best classified as:
A. Superficial (first degree)
B. Partial-thickness (second degree)
C. Full-thickness (third degree)
D. Deep tissue pressure injury

Correct: B

Explanation:
Partial-thickness burns (second degree) damage the epidermis and part of dermis. They are moist, blistered, red, blanchable, and painful due to exposed nerve endings. Superficial burns are red/dry without blisters (like sunburn). Full-thickness burns extend through the dermis, often appear dry, leathery, white/brown/black, and may be painless initially due to nerve destruction. DTPI is unrelated to burns. Nursing care includes pain management, infection prevention, fluid resuscitation for larger burns, and sterile dressing coverage. Deep partial-thickness burns may require grafting if healing stalls.

28) Moisture Barrier Use

What is the best prevention for incontinence-associated dermatitis?
A. Scrub skin vigorously with soap after each episode
B. Apply a protective moisture barrier cream or film regularly
C. Avoid cleaning to reduce skin breakdown
D. Use heat lamps to dry the perineal skin

Correct: B

Explanation:
Moisture barrier creams/films (zinc oxide, dimethicone) protect skin from urine/stool, the most effective prevention for IAD. Harsh scrubbing (Option A) disrupts skin barrier. Avoiding cleaning (Option C) promotes infection and breakdown. Heat lamps (Option D) are outdated and risk burns. Along with barriers, implement scheduled toileting, absorbent products, prompt cleansing with pH-balanced wipes, and pressure redistribution. Differentiating IAD from pressure injuries is vital, since treatment differs—moisture vs. pressure/shear etiology.

29) Postoperative Evisceration Emergency

A surgical patient suddenly reports a “popping” sensation and you observe eviscerated bowel loops. What is the first nursing action?
A. Cover with sterile saline-moistened gauze and notify provider immediately
B. Attempt to push the bowel back in and tape the incision closed
C. Apply an abdominal binder tightly and wait for the surgeon
D. Elevate head of bed to high-Fowler’s

Correct: A

Explanation:
Evisceration is a surgical emergency. The priority is to cover exposed viscera with sterile saline-moistened gauze to prevent drying and infection, maintain the patient supine with knees bent to reduce tension, and call the surgeon immediately. Never attempt to push bowel back (Option B)—this risks perforation. A binder (Option C) could worsen damage. High-Fowler’s (Option D) increases abdominal pressure; keep patient supine or low-Fowler’s. Prepare for surgical intervention. Frequent assessment and maintaining calm communication with the patient are also essential to reduce distress.

30) Documentation Best Practice

When documenting a pressure injury, which description is most appropriate?
A. “Bedsore improving, looks better”
B. “3 × 2 cm sacral ulcer, Stage 2, 0.2 cm depth, serous drainage, peri-wound intact”
C. “Patient has a small wound”
D. “Skin tear or pressure sore, not sure which”

Correct: B

Explanation:
Documentation should be objective, specific, and measurable: location, stage, size (length × width × depth), drainage type/amount, wound bed tissue, peri-wound condition, and pain level. Option B meets this standard. Vague terms like “bedsore” or “looks better” (Option A/C) are subjective and unhelpful. Option D reflects uncertainty; the nurse should describe findings factually rather than labeling without clarity. Clear documentation is essential for continuity of care, staging accuracy, monitoring progress, reimbursement, and legal protection. Photographs may also be used per facility policy.