Hondros Nur 150 Exam 2 Questions With Complete
Solutions
What puts a patient at risk for pressure sores? (7)
immobility, chronic illness, poor nutrition, poor circulation,
continence, same position
What do you document with wound care?
color, odor, consistency, amount (drainage), dressing we
remove/put on, pain tolerance, dressing change completely,
location, length, width, depth, teaching signs and symptoms,
date and time
Perulant
yellow, green, brown (infection)
serous
clear
sanguinous
bloody
Serosanguineous
pink
Braden Scale
A tool for predicting pressure ulcer risk
signs and symptoms of infection in the wound
, odor, redness, purlent, fever, WBC goes up, warmth, swelling -
edema
Nursing interventions to heal
turn and reposition every 2 hours, use protective cream (at stage
1), good nutrients, float heels, water, pillows on bony
prominences, keep skin dry and clean
When to assess skin?
in shower, beginning of shift, among admission
Anaerobic specimen collection
without oxygen, syringe
Aerobic Specimen Collection
with oxygen, swab (take drainage from inside wound)
What kind of lab test is done when you inspect infection?
Culture and sensitivity
What does heat help with?
Pain, 20 mins on, barrier between heating pad
What does cold help with?
good for inflammation, 20 mins at a time for 24 to 48 hours
2 things used to check function ability?
Katz (ADL) Lawton (IADL)
Things used to check dementia?
Montreal and mini cog
Solutions
What puts a patient at risk for pressure sores? (7)
immobility, chronic illness, poor nutrition, poor circulation,
continence, same position
What do you document with wound care?
color, odor, consistency, amount (drainage), dressing we
remove/put on, pain tolerance, dressing change completely,
location, length, width, depth, teaching signs and symptoms,
date and time
Perulant
yellow, green, brown (infection)
serous
clear
sanguinous
bloody
Serosanguineous
pink
Braden Scale
A tool for predicting pressure ulcer risk
signs and symptoms of infection in the wound
, odor, redness, purlent, fever, WBC goes up, warmth, swelling -
edema
Nursing interventions to heal
turn and reposition every 2 hours, use protective cream (at stage
1), good nutrients, float heels, water, pillows on bony
prominences, keep skin dry and clean
When to assess skin?
in shower, beginning of shift, among admission
Anaerobic specimen collection
without oxygen, syringe
Aerobic Specimen Collection
with oxygen, swab (take drainage from inside wound)
What kind of lab test is done when you inspect infection?
Culture and sensitivity
What does heat help with?
Pain, 20 mins on, barrier between heating pad
What does cold help with?
good for inflammation, 20 mins at a time for 24 to 48 hours
2 things used to check function ability?
Katz (ADL) Lawton (IADL)
Things used to check dementia?
Montreal and mini cog
