NLE Integumentary & Skin Integrity Reviewer 2026

Answer: A. Stage 1

Step 1: Recall that pressure injuries are staged by the depth of tissue destruction. Step 2: The key features here are INTACT skin and NON-BLANCHABLE erythema — the skin surface is not broken. Step 3: These are the classic hallmarks of a Stage 1 pressure injury. Step 4: Stage 2 involves partial-thickness skin loss (open ulcer or blister — the skin IS broken). Stage 3 and 4 involve full-thickness loss. Unstageable wounds have obscured bases. Step 5: Therefore, intact skin + non-blanchable erythema = Stage 1.

Answer: B. Stage 2

Step 1: The wound is described as a shallow open ulcer with a red-pink wound bed, OR an intact or ruptured serum-filled blister. Step 2: These are the defining characteristics of a Stage 2 pressure injury. Step 3: Stage 2 represents PARTIAL-THICKNESS skin loss — the epidermis and part of the dermis are involved, but no deeper structures are visible. Step 4: Stage 1 has intact skin; Stage 3 would show subcutaneous fat; DTI presents as intact or non-intact skin with deep purple/maroon discoloration or a blood-filled blister (NOT serum-filled). Step 5: A serum-filled (clear fluid) blister or shallow ulcer = Stage 2.

Answer: C. Stage 4

Step 1: The critical clue is 'bone is clearly visible.' Step 2: Stage 4 is defined as full-thickness skin and tissue loss with EXPOSED or directly palpable bone, tendon, muscle, ligament, or cartilage. Step 3: Stage 3 also involves full-thickness loss, but bone, tendon, and muscle are NOT exposed — only subcutaneous fat may be visible. Step 4: Unstageable wounds have a base covered/obscured by slough or eschar, so you cannot see the depth. Step 5: Since bone is VISIBLE, this is definitively Stage 4, which also carries the highest risk for osteomyelitis.

Answer: C. Unstageable

Step 1: The key rule is: if you CANNOT determine the depth of the wound because the base is obscured, you CANNOT stage it accurately. Step 2: When slough or eschar covers the wound base and hides the depth, the wound is classified as 'Unstageable.' Step 3: Once the slough is removed (debrided), the wound will likely be revealed as a Stage 3 or Stage 4. Step 4: DTI presents as a discoloration (purple/maroon) on INTACT or non-intact skin — it is NOT a wound filled with slough. Step 5: The defining feature of Unstageable = base OBSCURED by slough or eschar → depth unknown → cannot stage.

Answer: C. Deep Tissue Pressure Injury (DTI)

Step 1: The distinguishing feature here is the COLOR — deep purple, maroon, or dark red non-blanchable discoloration on intact or non-intact skin. Step 2: This color indicates damage to the DEEPER soft tissues beneath the skin surface, even though the skin may appear intact. Step 3: A DTI can also present as a blood-filled blister. It may evolve rapidly and reveal a larger wound than initially visible. Step 4: Stage 1 has non-blanchable ERYTHEMA (red, not purple/maroon). Stage 2 has partial-thickness loss (broken skin, shallow ulcer, or serum blister). Unstageable has obscured depth. Step 5: Deep purple/maroon + intact or non-intact skin = DTI. Think of it as an 'iceberg' — the visible surface does not reflect the true depth of injury.

Answer: B. Every 2 hours

Step 1: Pressure injuries develop when capillary blood flow is occluded by sustained pressure exceeding 32 mmHg. Step 2: Regular repositioning relieves pressure and restores blood flow before tissue ischemia becomes irreversible. Step 3: The standard recommendation is to reposition BEDBOUND (bedridden) patients at least every 2 HOURS. Step 4: For patients in a CHAIR or wheelchair, repositioning (or teaching independent weight shifts) is recommended every 1 HOUR (or every 15 minutes if the patient can do it independently). Step 5: Every 4 or 6 hours is too infrequent and allows prolonged pressure damage; every 30 minutes is impractical. Every 2 hours for bedbound patients is the clinical and NLE standard.

Answer: B. Inflammatory phase

Step 1: The wound is 2 days old. The healing phases are: Hemostasis (minutes), Inflammatory (days 1–4), Proliferative (days 4–21), and Maturation (day 21 to 1–2 years). Step 2: At day 2, the patient is in the INFLAMMATORY phase. Step 3: The classic signs — warmth (calor), redness (rubor), swelling (tumor), and pain (dolor) — are EXPECTED and NORMAL during the inflammatory phase, as vasodilation and leukocyte migration occur to clean the wound. Step 4: Hemostasis is immediate (within minutes of injury) — involves vasoconstriction and clot formation. Proliferative phase involves fibroblasts and granulation tissue (starts around day 4). Maturation involves collagen remodeling (weeks to months). Step 5: Day 2 + warmth/redness/swelling WITHOUT pus = NORMAL inflammatory phase, not infection.

Answer: C. Alginate dressing

Step 1: The key wound characteristics here are HEAVY EXUDATE and a DEEP wound requiring packing. Step 2: Alginate dressings (made from seaweed) are HIGHLY ABSORBENT and are specifically designed for wounds with heavy exudate. They can also be used to pack deep or tunneling wounds. Step 3: Transparent film is for superficial, low-exudate wounds — it would be overwhelmed by heavy drainage. Step 4: Hydrogel ADDS moisture to dry wounds — it is the opposite of what a wet wound needs. Step 5: Hydrocolloid handles only LIGHT-to-MODERATE exudate and is more appropriate for Stage 2 or shallow Stage 3. Alginate is the best match for heavy exudate + deep wound.

Answer: C. Normal saline (0.9% NaCl)

Step 1: A granulating wound has healthy red granulation tissue forming — this new tissue is fragile and must be protected. Step 2: Normal saline (0.9% NaCl) is the gold standard for wound irrigation because it is ISOTONIC, non-cytotoxic, and does not harm healing tissue. Step 3: Hydrogen peroxide destroys new granulation tissue and delays healing — it is CYTOTOXIC to new cells. Step 4: Povidone-iodine (Betadine) is also cytotoxic to fibroblasts and should NOT be used routinely on granulating wounds. Step 5: Alcohol is extremely irritating and desiccating — it damages both wound tissue and periwound skin. The NLE principle: clean granulating wounds with NORMAL SALINE only.

Answer: C. Report the finding immediately to the physician — this indicates stoma ischemia

Step 1: A healthy stoma is RED-PINK, MOIST, and slightly raised — this indicates good blood supply. Step 2: A DUSKY, DARK, PURPLE, or BLACK stoma signals ISCHEMIA — inadequate blood flow to the stoma tissue. Step 3: This is a SURGICAL EMERGENCY because ischemia can lead to stoma necrosis if not treated immediately. Step 4: The PRIORITY action, based on Maslow (physiological safety) and the nursing process, is to REPORT this finding IMMEDIATELY to the physician. Step 5: Simply applying a new appliance or reassuring the patient ignores a life-threatening complication. Documenting alone is insufficient — prompt medical intervention is needed.

Answer: A. Superficial (first-degree) burn

Step 1 – Identify the layer affected: The burn involves only the epidermis, the outermost skin layer. Step 2 – Match to classification: A burn involving only the epidermis is called a superficial or first-degree burn. Step 3 – Check the clinical features: First-degree burns are red, dry, painful, and blanch with pressure; they have NO blisters. Step 4 – Rule out the other options: Superficial partial-thickness (second-degree) burns have blisters and affect the upper dermis. Deep partial-thickness burns are drier with less pain. Full-thickness burns are leathery and painless. Step 5 – Key NLE point: First-degree burns are NOT counted in TBSA calculations for the Parkland formula.

Answer: B. 18%

Step 1 – Recall the Rule of Nines: The adult body is divided into regions that are multiples of 9%, totaling 100%. Step 2 – Identify the anterior trunk: The chest and abdomen together form the anterior trunk. Step 3 – Assign the percentage: The anterior trunk = 18% TBSA. Step 4 – Compare with other regions: The head/neck = 9%, each arm = 9%, the posterior trunk = 18%, each leg = 18%, and the perineum = 1%. Step 5 – Why the wrong answers are incorrect: 9% would be for only one arm or the head/neck; 36% would be the entire trunk combined (anterior + posterior); 1% is the perineum.