NLE Integumentary & Skin Integrity — Skin Integrity and Wound CareExam Answer Templates

Marks

1

Topic

Physiology of Pressure Injury

Difficulty

easy

Template Id

T1

Examiner Tip

A 1-mark definition question rewards completeness in one sentence. If you include the cause AND the mechanism, you are guaranteed the mark. Do not leave out 'ischemia' — it is the physiological core of the definition.

Model Answer

A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by sustained pressure or pressure combined with shear, resulting in tissue ischemia.

Question Type

very_short_answer

Answer Structure

• One complete sentence: Define pressure injury, include cause (sustained pressure/shear), location (bony prominence), and mechanism (tissue ischemia) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing 'decubitus ulcer' only without explaining what it is
• Omitting the mechanism (ischemia) — definition is incomplete without it
• Writing 'caused by lying down for a long time' — too vague, not clinical

Key Phrases To Include

• localized damage
• skin and underlying soft tissue
• bony prominence
• sustained pressure or pressure combined with shear
• tissue ischemia

Marks

1

Topic

Pressure Injury Staging

Difficulty

easy

Template Id

T2

Examiner Tip

The single most tested fact about Stage 1 is that the skin is still INTACT. Non-blanchable erythema is the distinguishing sign. If you forget everything else, remember: Stage 1 = intact skin + non-blanchable redness.

Model Answer

A Stage 1 pressure injury presents as intact skin with non-blanchable erythema over a localized area, usually over a bony prominence. In darkly pigmented skin, the area may differ in color, temperature, or firmness from surrounding tissue rather than showing obvious redness.

Question Type

very_short_answer

Answer Structure

• State that skin is INTACT [key distinguishing feature]
• State non-blanchable erythema [1 mark]
• Bonus clarity: mention darkly pigmented skin variation

Scoring Breakdown

Common Mark Deductions

• Saying 'open wound with redness' — Stage 1 has INTACT skin; writing 'open' is a critical error
• Confusing Stage 1 with Stage 2 by mentioning a blister or skin loss
• Omitting 'non-blanchable' — blanchable redness is a normal response, not a pressure injury

Key Phrases To Include

• intact skin
• non-blanchable erythema
• localized area
• bony prominence
• darkly pigmented skin

Marks

2

Topic

Pressure Injury Staging

Difficulty

medium

Template Id

T3

Examiner Tip

The NLE frequently tests the distinction between Stage 3 and Stage 4. The one-word answer is 'exposed': Stage 3 has fat visible but no bone/tendon/muscle exposed; Stage 4 has bone/tendon/muscle exposed. Memorize this contrast and you will always earn both marks.

Model Answer

Stage 3 is a full-thickness skin loss where subcutaneous fat may be visible, but bone, tendon, and muscle are NOT exposed. Slough and eschar may be present, and undermining or tunneling can occur. Stage 4 is a full-thickness skin and tissue loss where bone, tendon, muscle, ligament, or cartilage is exposed or directly palpable. It carries the highest risk for osteomyelitis due to deep tissue involvement.

Question Type

short_answer

Answer Structure

• Line 1-2: Define Stage 3 — full-thickness, fat visible, bone/tendon/muscle NOT exposed [1 mark]
• Line 3-4: Define Stage 4 — full-thickness, bone/tendon/muscle EXPOSED, risk for osteomyelitis [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying Stage 3 exposes bone — this is the Stage 4 criterion, a critical factual error
• Not using the word 'exposed' for Stage 4 — this is the key distinguishing term
• Forgetting to mention osteomyelitis risk for Stage 4 (common examiner expectation)
• Writing 'deeper' without specifying what tissue is or is not exposed

Key Phrases To Include

• full-thickness skin loss
• subcutaneous fat visible
• bone tendon muscle NOT exposed
• bone tendon muscle exposed or palpable
• osteomyelitis
• Stage 3
• Stage 4

Marks

2

Topic

Wound Assessment and Debridement

Difficulty

medium

Template Id

T4

Examiner Tip

This is a high-yield NLE 'exception' question. Examiners love exceptions because they test true understanding, not just memorization. Always state the rule first, then the specific exception, then the rationale. This three-part structure earns full marks.

Model Answer

Stable, dry, adherent, and intact eschar on the heel of an ischemic limb should NOT be removed because it acts as the body's natural protective cover. In an ischemic limb, the blood supply is already compromised; removing the eschar disrupts this barrier, exposes underlying tissue, introduces pathogens, and can worsen tissue necrosis and lead to serious complications such as infection or amputation. The eschar should be monitored for signs of instability (erythema, fluctuance, or drainage) instead.

Question Type

short_answer

Answer Structure

• State the rule clearly: stable dry eschar on ischemic heel should NOT be removed [1 mark]
• Give the rationale: acts as natural protective cover; removal exposes tissue and risks infection/necrosis in a limb with compromised blood supply [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying 'eschar should always be removed for debridement' — this is wrong for this specific context
• Failing to explain WHY (the rationale about ischemia and blood supply)
• Confusing stable eschar with unstable eschar (with erythema or fluctuance)

Key Phrases To Include

• stable dry adherent intact eschar
• ischemic limb
• natural protective cover
• compromised blood supply
• do not remove
• monitor for instability

Marks

3

Topic

Pressure Injury Staging

Difficulty

medium

Template Id

T5

Examiner Tip

In a 3-mark enumeration, examiners typically award marks in pairs: Stages 1–2, Stages 3–4, and Unstageable/DTI. Structure your answer in that grouping to make grading easy and to ensure you cover all six. Numbered lists are cleaner and faster to grade than paragraphs.

Model Answer

The six pressure injury classifications according to NPUAP/NPIAP are: 1. Stage 1 — Intact skin with non-blanchable erythema over a bony prominence. 2. Stage 2 — Partial-thickness skin loss exposing the dermis; presents as a shallow open ulcer or intact/ruptured serum-filled blister. 3. Stage 3 — Full-thickness skin loss with visible subcutaneous fat; bone, tendon, and muscle are NOT exposed. 4. Stage 4 — Full-thickness skin and tissue loss with exposed or directly palpable bone, tendon, muscle, ligament, or cartilage. 5. Unstageable — Full-thickness loss where the base is obscured by slough or eschar, making depth (and therefore stage) indeterminate. 6. Deep Tissue Pressure Injury (DTI) — Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister, from damage to underlying soft tissue.

Question Type

short_answer

Answer Structure

• Label each stage with its number and name [organizes the answer]
• For Stage 1 and Stage 2: state the key distinguishing feature [1 mark]
• For Stage 3 and Stage 4: distinguish by depth of tissue exposed [1 mark]
• For Unstageable and DTI: describe each correctly [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing only 4 stages (forgetting Unstageable and DTI) — loses 1 mark
• Confusing DTI with Stage 1 (both involve intact skin but differ in color and depth of damage)
• Writing 'Grade' instead of 'Stage' — use NPUAP/NPIAP terminology
• Not specifying that Stage 3 does NOT have bone/tendon exposed — this is a critical differentiator

Key Phrases To Include

• non-blanchable erythema
• partial-thickness
• dermis
• serum-filled blister
• full-thickness
• subcutaneous fat visible
• bone tendon muscle exposed
• slough or eschar obscures base
• deep red maroon or purple discoloration
• blood-filled blister

Marks

3

Topic

Wound Assessment and Pressure Injury Staging

Difficulty

hard

Template Id

T6

Examiner Tip

Case-study questions test clinical reasoning, not just recall. Always state your answer (the stage), then prove it with a rationale, then eliminate the other stages logically. This ABCDE structure (Answer, Because, Contrast, Describe, Evaluate) earns full marks on case-based staging questions.

Model Answer

Stage of Pressure Injury: Stage 3 Rationale: The wound shows full-thickness skin loss with visible subcutaneous fat. Although slough is present, it does not obscure the depth of the wound (the fat is still visible), so the wound can be staged. There is no exposed bone, tendon, or muscle, which distinguishes it from Stage 4. Wound Assessment Findings: • Location: Sacrum (common bony prominence in bedridden patients) • Tissue in wound bed: Subcutaneous fat visible; slough (yellow/tan nonviable tissue) also present • Tunneling: Present at the 3 o'clock position, measuring 3 cm — indicating tissue destruction extending beyond the visible wound margins • Exudate: Not specified in the scenario but should be assessed and documented (type and amount) • Periwound skin: Should be assessed for maceration, induration, or erythema

Question Type

case_study

Answer Structure

• State the stage (Stage 3) and provide rationale [1 mark]
• Explain why it is NOT Stage 4 (no bone/tendon exposure) and NOT Unstageable (depth is visible) [1 mark]
• Describe wound assessment findings: tissue type, tunneling with clock position and depth, periwound skin [1 mark]

Scoring Breakdown

Common Mark Deductions

• Labeling as Unstageable because slough is present — slough makes it Unstageable only if it obscures the entire wound base so depth cannot be determined
• Labeling as Stage 4 because of severity — no bone/tendon is mentioned as exposed
• Forgetting to document tunneling using clock position — this is the standard clinical documentation format
• Not providing a rationale for the staging decision

Key Phrases To Include

• Stage 3
• full-thickness skin loss
• subcutaneous fat visible
• slough does not obscure depth
• no bone tendon muscle exposed
• tunneling at 3 o'clock position
• clock position for tunneling
• periwound skin assessment

Marks

2

Topic

Nursing Management — Pressure Injury Prevention

Difficulty

medium

Template Id

T7

Examiner Tip

The most commonly missed fact about the Braden Scale in NLE is the scoring direction. It is counter-intuitive: you might think a higher score means more problems, but it is the opposite. Write it in bold in your answer: LOWER SCORE = HIGHER RISK. Examiners look for this explicitly.

Model Answer

The Braden Scale is a validated risk assessment tool used to predict a patient's risk for developing pressure injuries. It evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each subscale is scored from 1 (most impaired) to 3 or 4 (least impaired), with a maximum total score of 23. Interpretation: A LOWER Braden score indicates HIGHER risk. A score of 18 or below generally indicates at-risk status; scores of 9–12 indicate very high risk. Clinical interventions are intensified as the score decreases.

Question Type

short_answer

Answer Structure

• Define the Braden Scale and list its six subscales [1 mark]
• Explain score interpretation: lower score = higher risk, state a threshold value [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying 'higher score = higher risk' — this is the OPPOSITE of the correct interpretation
• Listing fewer than all six subscales without noting that some were omitted
• Confusing the Braden Scale with the Norton Scale (similar purpose but different subscales)

Key Phrases To Include

• validated risk assessment tool
• pressure injury risk
• sensory perception
• moisture
• activity
• mobility
• nutrition
• friction and shear
• lower score higher risk
• score of 18 or below

Marks

3

Topic

Types and Phases of Wound Healing

Difficulty

medium

Template Id

T8

Examiner Tip

A useful mnemonic for the phases is HIPM: Hemostasis, Inflammatory, Proliferative, Maturation. Write the phase name, its timeframe, and its key activity. Three-mark answers reward this systematic, complete approach. Including '70–80% tensile strength' in the Maturation phase often earns bonus points from impressed examiners.

Model Answer

The four phases of wound healing in sequence are: 1. Hemostasis (Immediate) — Vasoconstriction occurs and a platelet plug and fibrin clot form to stop bleeding immediately after injury. 2. Inflammatory Phase (Days 1–4) — Vasodilation increases blood flow to the area. Leukocytes migrate to the wound and phagocytosis removes debris and bacteria. Clinical signs include warmth, edema, pain, and erythema — these are expected and normal. 3. Proliferative Phase (Days 4–21) — Fibroblasts produce collagen, granulation tissue forms, and epithelialization begins as new epithelial cells migrate across the wound surface from the edges. 4. Maturation/Remodeling Phase (Day 21 to 1–2 years) — Collagen fibers reorganize to increase tensile strength. A fully healed wound achieves only approximately 70–80% of its original tensile strength.

Question Type

short_answer

Answer Structure

• Name and describe Hemostasis with its mechanism [part of mark 1]
• Name and describe the Inflammatory Phase with its timeframe and clinical signs [1 mark]
• Name and describe the Proliferative Phase — granulation, collagen, epithelialization [1 mark]
• Name and describe the Maturation Phase — collagen remodeling, tensile strength 70–80% [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing phases out of order (e.g., proliferative before inflammatory)
• Omitting Hemostasis as a separate phase (students often list only three phases starting with Inflammatory)
• Not including the timeframes — examiners expect these as they demonstrate clinical knowledge
• Writing 'scab formation' instead of using correct clinical terms like fibrin clot and platelet plug

Key Phrases To Include

• hemostasis
• vasoconstriction
• fibrin clot
• inflammatory phase
• phagocytosis
• leukocyte migration
• proliferative phase
• fibroblasts
• granulation tissue
• epithelialization
• maturation remodeling
• tensile strength
• 70–80% original strength

Marks

3

Topic

Types and Phases of Wound Healing

Difficulty

medium

Template Id

T9

Examiner Tip

Use the number of closures as your memory hook: Primary = closed right away (1 step); Secondary = never surgically closed (0 step closure); Tertiary = closed later (delayed step). Clinical examples make your answer concrete and show examiners you can apply concepts to practice.

Model Answer

1. Primary Intention — Wounds with well-approximated (closely brought together) edges with minimal tissue loss, such as a clean surgical incision closed with sutures. Healing is fastest, scarring is minimal, and infection risk is low. 2. Secondary Intention — Wounds with significant tissue loss that are left open to heal by granulation tissue forming from the base upward (e.g., a Stage 3 pressure injury). Healing is slower, scarring is greater, and infection risk is higher. 3. Tertiary (Delayed Primary) Intention — A wound left open initially (to allow drainage or resolve infection) and then surgically closed at a later time. This combines elements of both primary and secondary intention and is used when immediate closure is not safe.

Question Type

short_answer

Answer Structure

• Describe Primary Intention: approximated edges, surgical wound, minimal loss, fastest healing [1 mark]
• Describe Secondary Intention: significant tissue loss, heals from base up by granulation, slower, more scarring [1 mark]
• Describe Tertiary Intention: initially open, later surgically closed, rationale for delayed closure [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing secondary intention with tertiary intention — remember: secondary stays open permanently; tertiary is later closed
• Not providing a clinical example for primary intention (sutured incision is the standard example)
• Omitting tertiary intention entirely — students often only know two types

Key Phrases To Include

• primary intention
• well-approximated edges
• secondary intention
• heals by granulation
• from the base up
• tertiary intention
• delayed primary intention
• left open initially
• surgically closed later

Marks

3

Topic

Nursing Management — Pressure Injury Prevention

Difficulty

medium

Template Id

T10

Examiner Tip

NLE intervention questions reward specificity. 'Reposition the patient every 2 hours' earns more than 'reposition the patient regularly.' Always include the timeframe, technique, and a brief rationale. The 'do NOT massage bony prominences' point is a classic NLE trap — many students do the opposite.

Model Answer

Five evidence-based nursing interventions to prevent pressure injuries in a bedridden patient: 1. Reposition the patient at least every 2 hours using a scheduled repositioning plan; use the 30-degree lateral tilt rather than direct side-lying on the trochanter to reduce pressure. 2. Offload the heels by placing pillows under the calves so that the heels 'float' and are completely free of the mattress surface. 3. Keep the head of the bed (HOB) at or below 30 degrees when clinically safe to minimize shear forces on the sacral area. 4. Use pressure-redistribution support surfaces such as foam, alternating-pressure, or low-air-loss mattresses to distribute body weight evenly. 5. Maintain skin cleanliness and dryness: cleanse skin promptly after incontinence using pH-balanced cleansers and apply moisture-barrier creams; do NOT massage over bony prominences as this can cause deep tissue damage.

Question Type

short_answer

Answer Structure

• List 5 distinct, specific interventions (not vague statements like 'provide good care')
• Each intervention should include the action AND the rationale [1 mark per 1–2 well-described interventions]
• Distribute marks: repositioning + heel offloading [1 mark], HOB + pressure surfaces [1 mark], skin care + no massage [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing vague interventions like 'turn patient often' without specifying the 2-hour interval
• Recommending massage over bony prominences — this is CONTRAINDICATED and will result in a mark deduction
• Giving fewer than 5 interventions when 5 are requested
• Not including rationale when the question implies clinical understanding is expected

Key Phrases To Include

• reposition every 2 hours
• 30-degree lateral tilt
• float the heels
• head of bed at or below 30 degrees
• pressure-redistribution surface
• pH-balanced cleanser
• moisture-barrier cream
• do not massage bony prominences

Marks

3

Topic

Dressing Selection

Difficulty

medium

Template Id

T11

Examiner Tip

Use this memory trick for dressings: 'GEL adds water' (hydroGEL for DRY wounds); 'COLLOID holds a little' (hydroCOLLOID for LIGHT exudate); 'ALGINATE absorbs A LOT' (for HEAVY exudate). These associations make NLE dressing questions fast to answer.

Model Answer

(a) Dry wound needing moisture → Hydrogel dressing Rationale: Hydrogel adds moisture to dry wounds, supports autolytic debridement, and is soothing for painful wounds. It maintains the moist wound environment that promotes faster epithelialization. (b) Wound with heavy exudate requiring packing → Alginate dressing (Calcium alginate) Rationale: Alginate is derived from seaweed, is highly absorbent, can be packed into deep or tunneling wounds, and can aid in hemostasis. It is the dressing of choice for heavy exudate and wound packing. (c) Stage 2 pressure injury with light-to-moderate exudate → Hydrocolloid dressing (e.g., DuoDERM) Rationale: Hydrocolloid is occlusive, supports autolytic debridement, and can remain in place for 3–7 days. It is appropriate for Stage 2 and shallow Stage 3 wounds with light-to-moderate exudate.

Question Type

short_answer

Answer Structure

• Match (a) correctly to Hydrogel + rationale [1 mark]
• Match (b) correctly to Alginate + rationale [1 mark]
• Match (c) correctly to Hydrocolloid + rationale [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing hydrogel (adds moisture) with hydrocolloid (absorbs light-moderate exudate) — these are frequently mixed up
• Using 'gauze' as an answer — while sometimes used, it is not the evidence-based answer for these specific scenarios
• Not providing rationale when the question is a 3-mark item (rationale earns the mark)

Key Phrases To Include

• hydrogel
• adds moisture
• alginate
• calcium alginate
• highly absorbent
• wound packing
• heavy exudate
• hydrocolloid
• DuoDERM
• light-to-moderate exudate
• autolytic debridement
• 3–7 days

Marks

5

Topic

Ostomy Skin Care — Stomal Complications

Difficulty

hard

Template Id

T12

Examiner Tip

Five-mark case study questions in the NLE reward the ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) structure. Always open with the PRIORITY action (not the first thing to do chronologically, but the MOST IMPORTANT). Mentioning RA 9173 in a Philippine NLE question demonstrates awareness of your legal scope of practice, which is always rewarded. This is one of the highest-value skills you can demonstrate as a future Philippine registered nurse.

Model Answer

PRIORITY ACTION: Report the finding IMMEDIATELY to the physician/surgeon and do not leave the patient. This is a clinical emergency. A dark purple or dusky stoma indicates stomal ischemia — inadequate blood supply to the stoma tissue. A healthy stoma should be red-pink, moist, and slightly raised above the skin surface. A stoma that is dark purple, maroon, black, cool, or dusky signals compromised vascular supply, which can rapidly progress to stomal necrosis (tissue death) and life-threatening complications. NURSING PROCESS APPLICATION: Assessment: Document the stoma color (dark purple), temperature (cool to touch), and compare with baseline post-operative assessment. Note any associated symptoms: abdominal pain, decreased or absent ostomy output, or odor. Nursing Diagnosis (NANDA): Ineffective Tissue Perfusion (Gastrointestinal/Peripheral) related to compromised vascular supply to the stoma as evidenced by dark purple discoloration and cool temperature of stomal tissue. Planning/Goal: Restore or preserve stomal tissue perfusion and prevent stomal necrosis. Implementation: 1. Immediately notify the surgeon — this is a surgical emergency requiring prompt evaluation. 2. Monitor vital signs for signs of systemic deterioration (hypotension, tachycardia, fever). 3. Keep the patient NPO (nothing per mouth) in anticipation of possible surgical intervention. 4. Document findings thoroughly with time of observation. 5. Do NOT attempt to manipulate or irrigate the stoma independently. 6. Provide emotional support to the patient and family, as surgical revision may be necessary. Evaluation: Surgeon arrives promptly; stomal tissue perfusion is assessed. Intervention may include surgical revision of the stoma if necrosis is confirmed. Philippine Context: Under RA 9173 (Philippine Nursing Act of 2002), the nurse's scope of practice includes independent assessment, documentation, and referral. Calling the surgeon immediately and documenting accurately are within the nurse's legal and professional obligation.

Question Type

case_study

Answer Structure

• State the priority action clearly and immediately (notify surgeon — emergency) [1 mark]
• Explain WHY it is an emergency (ischemia, necrosis risk, contrast with normal stoma appearance) [1 mark]
• Apply assessment findings and formulate a NANDA nursing diagnosis [1 mark]
• List at least 3 specific nursing interventions with rationale [1 mark]
• Mention evaluation criteria and include a reference to RA 9173 or Philippine nursing scope of practice [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying the nurse should apply a warm compress to the stoma — this is incorrect and dangerous management
• Not identifying this as an emergency — students who say 'document and monitor' without reporting lose 2+ marks
• Writing a nursing diagnosis without the 'related to' and 'as evidenced by' components — incomplete NANDA format
• Omitting RA 9173 or Philippine nursing practice context in a 5-mark NLE question
• Not differentiating the normal stoma appearance from the emergency finding

Key Phrases To Include

• stomal ischemia
• dark purple or dusky stoma
• clinical emergency
• immediately notify the surgeon
• healthy stoma is red-pink and moist
• stomal necrosis
• Ineffective Tissue Perfusion
• NANDA nursing diagnosis
• RA 9173
• scope of nursing practice
• NPO
• monitor vital signs
• document findings

Marks

2

Topic

Pressure Injury Staging — Unstageable and DTI

Difficulty

hard

Template Id

T13

Examiner Tip

Both Unstageable and DTI involve some uncertainty, which is what confuses students. Use this contrast: Unstageable = you CAN see there is a wound but CANNOT see the bottom; DTI = the surface LOOKS almost okay but the damage is DEEP underneath. This mental image will make the NLE question straightforward.

Model Answer

Unstageable Pressure Injury: This is a full-thickness skin and tissue loss where the true depth cannot be determined because the wound base is completely obscured by slough (yellow/tan) or eschar (black/brown). Once the slough or eschar is removed, the wound will be classified as a Stage 3 or Stage 4. Deep Tissue Pressure Injury (DTI): This involves intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, OR a blood-filled blister, resulting from pressure damage to the underlying soft tissue. The skin surface may still appear relatively intact but there is significant damage beneath it. DTI can evolve rapidly into a deeper wound even with treatment.

Question Type

short_answer

Answer Structure

• Describe Unstageable: full-thickness, base obscured by slough/eschar, true depth unknown [1 mark]
• Describe DTI: intact or near-intact skin, deep red/maroon/purple discoloration or blood-filled blister, damage is underneath, can worsen rapidly [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing DTI (intact skin, purple/maroon) with Stage 1 (intact skin, non-blanchable erythema) — the color and depth of damage differ
• Saying Unstageable and DTI are the same — they are two separate classifications
• Not mentioning that Unstageable resolves to Stage 3 or 4 after debridement

Key Phrases To Include

• Unstageable
• slough or eschar obscures base
• true depth cannot be determined
• will be Stage 3 or 4 once debrided
• DTI
• Deep Tissue Pressure Injury
• persistent non-blanchable
• deep red maroon or purple
• blood-filled blister
• underlying soft tissue damage
• may evolve rapidly

Marks

2

Topic

Wound Care Principles

Difficulty

medium

Template Id

T14

Examiner Tip

This question tests whether you know the 'why' behind wound care guidelines. The keyword examiners look for is 'cytotoxic.' If you write 'hydrogen peroxide is cytotoxic and destroys granulation tissue and fibroblasts,' you have demonstrated evidence-based reasoning and will earn full marks.

Model Answer

Normal saline (0.9% NaCl) is the preferred wound cleanser for granulating wounds because it is isotonic and non-cytotoxic — it cleanses without damaging the new, fragile tissue forming in the wound bed. Hydrogen peroxide and povidone-iodine are cytotoxic agents. While they are effective antiseptics for intact skin, they damage and destroy fibroblasts, epithelial cells, and granulation tissue in an open wound — the very cells responsible for wound healing. Routine use of these agents in granulating wounds therefore delays healing, destroys new tissue, and is considered a practice to avoid in evidence-based wound care.

Question Type

short_answer

Answer Structure

• State what normal saline is and why it is preferred (isotonic, non-cytotoxic, safe for new tissue) [1 mark]
• Explain why hydrogen peroxide and povidone-iodine are harmful to granulating wounds (cytotoxic, damage fibroblasts and epithelial cells, delay healing) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Saying hydrogen peroxide or povidone-iodine should be used on any open wound — this contradicts evidence-based guidelines
• Not explaining WHY normal saline is preferred (just listing it without rationale earns half credit)
• Confusing cytotoxic with antibiotic — cytotoxic means toxic to cells (including healthy healing cells)

Key Phrases To Include

• normal saline
• isotonic
• non-cytotoxic
• granulation tissue
• hydrogen peroxide
• povidone-iodine
• cytotoxic
• damages fibroblasts and epithelial cells
• delays wound healing

Marks

5

Topic

Ostomy Skin Care — Patient Education

Difficulty

hard

Template Id

T15

Examiner Tip

For 5-mark discharge teaching questions, structure your answer with numbered points and clear headings. Use the format: TOPIC — what to teach — why it matters. This structure earns marks for each component. In the NLE, Philippine nursing law (RA 9173) is always relevant for questions about nurse's roles and responsibilities — always weave it in for a 5-mark answer.

Model Answer

As the discharging nurse, I will provide the following evidence-based education to the patient with an ileostomy before discharge: 1. APPLIANCE MANAGEMENT — Empty the pouch when it is one-third to one-half full to prevent leakage and skin damage. Change the entire appliance every 3–7 days or immediately if leaking. Cut the wafer/barrier opening approximately 1–2 mm larger than the stoma so it fits snugly — too large an opening exposes peristomal skin to damaging effluent; too tight an opening can injure the stoma tissue. 2. PERISTOMAL SKIN CARE — Cleanse the peristomal skin with water only (avoid soaps containing oils or lotions as these impair adhesion of the wafer). Pat dry thoroughly before applying the appliance. Apply skin barrier products as prescribed to protect the skin from enzymatic ileostomy output, which is liquid and rich in digestive enzymes that can rapidly break down skin. 3. MONITORING FOR COMPLICATIONS — Teach the patient to assess the stoma daily. A healthy stoma is red-pink, moist, and slightly raised. Instruct the patient to call the physician or ET (Enterostomal Therapy) nurse immediately if the stoma becomes dark, purple, or black (ischemia emergency) or if they observe peristomal complications such as redness, itching, skin breakdown (dermatitis), or white patches (candidiasis). 4. FLUID AND ELECTROLYTE MANAGEMENT — Because ileostomy output is liquid and continuous, patients are at high risk for dehydration and electrolyte loss (especially sodium and potassium). Teach the patient to drink at least 8–10 glasses of water per day, to consume sodium- and potassium-rich foods (bananas, oranges, sports drinks in moderation), and to recognize signs of dehydration (dry mouth, decreased urine output, dizziness). Philippine Context: Under RA 9173, patient education and health teaching is a core independent nursing function. Ensuring patient competence in ostomy self-care before discharge is both a legal and ethical responsibility of the registered nurse in the Philippines.

Question Type

case_study

Answer Structure

• Education Point 1: Appliance management — pouch emptying (1/3 to 1/2 full), change frequency, wafer sizing (1–2 mm) [1 mark]
• Education Point 2: Peristomal skin care — water only, pat dry, skin barrier, enzyme-rich output risk [1 mark]
• Education Point 3: Complication monitoring — normal vs. abnormal stoma, emergency signs (dark/purple/black), dermatitis, candidiasis [1 mark]
• Education Point 4: Fluid and electrolyte management — dehydration risk, sodium/potassium loss, fluid intake recommendation [1 mark]
• Reference to RA 9173 and patient teaching as a core nursing responsibility [1 mark]

Scoring Breakdown

Common Mark Deductions

• Giving generic health teaching ('eat well,' 'take care of yourself') without specific ostomy care instructions
• Not mentioning the wafer sizing (1–2 mm) — a frequently tested specific measurement
• Forgetting fluid and electrolyte management for ileostomy — this is a high-risk and frequently tested topic
• Not referencing RA 9173 or Philippine nursing legal framework in a 5-mark NLE question
• Describing a colostomy instead of an ileostomy — they differ in output consistency and enzyme content

Key Phrases To Include

• empty pouch one-third to one-half full
• change appliance every 3–7 days
• wafer opening 1–2 mm larger than stoma
• water only no oily soaps
• pat dry
• skin barrier
• enzyme-rich ileostomy output
• red-pink moist healthy stoma
• dark purple black stoma emergency
• peristomal dermatitis
• candidiasis
• dehydration risk
• sodium and potassium loss
• RA 9173
• patient health education