NURS 356 FINAL EXAM VERIFIED
QUESTIONS AND CORRECT
ANSWERS
Stage 1 Pressure Ulcer - CORRECT ANSWER- Skin is intact
When skin is pressed, it does not turn a lighter color (nonblanchable)
Primary goal: Prevent skin breakage
Stage 2 Pressure Ulcer - CORRECT ANSWER- Shallow, open ulcer
Can be a blister with serous or serosangineous fluid
Partial-thickness loss of epidermis
Red/pink wound bed
Stage 3 Pressure Ulcer - CORRECT ANSWER- Full-thickness tissue
loss
May see subcutaneous fat
Sloughing may be present (shedding of cells)
Eschar may be present (dry, dark scab- dead tissue)
Possible undermining and tunneling
Stage 4 Pressure Ulcer - CORRECT ANSWER- Full-thickness tissue
loss
Exposed bone, tendon, or muscle
Possible slough or eschar
Often undermining & tunneling
Unstageable Pressure Ulcer - CORRECT ANSWER- Base of wound
is not visible
Full-thickness tissue loss
Completely obscured by slough or eschar
Necrotic tissue
*Whenever there is necrosis, eschar --> unstageable!!! *
, Any alteration in skin integrity? - CORRECT ANSWER- A wound
Types of Drainage - CORRECT ANSWER- Serous: clear fluid, or
slightly white or yellow
Serosanguinous: serous with a little blood
Sanguineous: red blood
Purulent: white pus, thick can be also yellow, green, tan, brown
Complications of wound healing - CORRECT ANSWER-
Hemorrhage: internal or external; 24-48 hrs after injury
Infection: purulent drainage or positive culture
Dehiscence
Evisceration
Dehiscence - CORRECT ANSWER- -Layers of skin and tissue
separate
-Obesity, increased pressure
Evisceration - CORRECT ANSWER- -Visceral organs come through
the wound opening
-Surgical emergency
Debride - CORRECT ANSWER- Mechanical, chemical, surgical way
to remove dead cells/ tissue
Enteral Nutrition (EN) - CORRECT ANSWER- GI tract
Preferred route
Keeps the gut working which prevents bacteria from leaking into
surrounding tissues
Must verify tube placement by xray
Variety of tube types
Nasogastric (NG)/Orogastric (OG)
QUESTIONS AND CORRECT
ANSWERS
Stage 1 Pressure Ulcer - CORRECT ANSWER- Skin is intact
When skin is pressed, it does not turn a lighter color (nonblanchable)
Primary goal: Prevent skin breakage
Stage 2 Pressure Ulcer - CORRECT ANSWER- Shallow, open ulcer
Can be a blister with serous or serosangineous fluid
Partial-thickness loss of epidermis
Red/pink wound bed
Stage 3 Pressure Ulcer - CORRECT ANSWER- Full-thickness tissue
loss
May see subcutaneous fat
Sloughing may be present (shedding of cells)
Eschar may be present (dry, dark scab- dead tissue)
Possible undermining and tunneling
Stage 4 Pressure Ulcer - CORRECT ANSWER- Full-thickness tissue
loss
Exposed bone, tendon, or muscle
Possible slough or eschar
Often undermining & tunneling
Unstageable Pressure Ulcer - CORRECT ANSWER- Base of wound
is not visible
Full-thickness tissue loss
Completely obscured by slough or eschar
Necrotic tissue
*Whenever there is necrosis, eschar --> unstageable!!! *
, Any alteration in skin integrity? - CORRECT ANSWER- A wound
Types of Drainage - CORRECT ANSWER- Serous: clear fluid, or
slightly white or yellow
Serosanguinous: serous with a little blood
Sanguineous: red blood
Purulent: white pus, thick can be also yellow, green, tan, brown
Complications of wound healing - CORRECT ANSWER-
Hemorrhage: internal or external; 24-48 hrs after injury
Infection: purulent drainage or positive culture
Dehiscence
Evisceration
Dehiscence - CORRECT ANSWER- -Layers of skin and tissue
separate
-Obesity, increased pressure
Evisceration - CORRECT ANSWER- -Visceral organs come through
the wound opening
-Surgical emergency
Debride - CORRECT ANSWER- Mechanical, chemical, surgical way
to remove dead cells/ tissue
Enteral Nutrition (EN) - CORRECT ANSWER- GI tract
Preferred route
Keeps the gut working which prevents bacteria from leaking into
surrounding tissues
Must verify tube placement by xray
Variety of tube types
Nasogastric (NG)/Orogastric (OG)
