NSE 211 Final Exam – Study Guide & Practice Questions
wound - (answer)break in the continuity of body structure, caused by violence, trauma, or surgery to
tissue bodies
ex; of acute wounds - (answer)surgical incisions, traumatic wounds, lacerations, burns
ex; of chronic wounds - (answer)PI, diabetic ulcers, malignant
acute wound - (answer)wound that proceeds through an orderly & timely reparative process -->
sustained restoration of anatomical & functional integrity
phases of wound healing - (answer)1) inflammatory phase
2) proliferative phase
3) remodelling phase
what's a part of the proliferative phase? - (answer)proliferation, granulation & contraction
what happens during inflammatory phase? - (answer)1) hemostasis. (vasoconstriction)
2) platelets + fibrin forms, clot formation
3) histamina, vasodilation, increased capillary permeability, erythema, swelling & warmth
what happens day 1-3 inflammatory phase? - (answer)neutrophils released to injury site, phagocytosis
of debris beings.
what happens during day 3-24 of proliferative phase? - (answer)1) granulation tissue appears in wound
2) contraction of wound edges
3) resurfacing by epithelialization --> dermal regen.
4) vascular bed reestablished
,NSE 211 Final Exam – Study Guide & Practice Questions
what happens during day 24-2 yrs of remodelling phase? - (answer)1) collagen fibers reorganize &
remodel
2) permanent scar
3) attains 80% of original strength
Primary intention healing - (answer)wound that is closed by suture or wound closers & healing occurs by
collagen synthesis; lower risk of infection, and heals quickly w/ minimal scarring.
secondary intention healing - (answer)wound edges are not approximated. heals by granulation tissue
formation, wound contraction & epithelialization.
has a prolonged phase of inflammation due to increased time needed for phagocytosis of necrotic
tissue.
tertiary intention healing - (answer)wound is left open for several days as it could be contaminated. has
an increased risk of infection, so closure of wound is done later until risk of infection is resolved.
why is the wound kept open for tertiary healing? - (answer)to allow exudate to drain, prevent the
spread of deep infection & aiding granulation.
medical asepsis - (answer)aka, *clean technique*.
includes procedures used to reduce & prevent the spread of microorganisms
ex; of medical asepsis - (answer)hand washing, clean gloves, cleaning environment routinely.
ex; of surgical asepsis - (answer)aka *surgical technique*.
requires more stringent techniques, *eliminating all microorganisms*.
when do you use surgical asepsis? - (answer)when a patient's kin is broken, or if the nurse performs an
invasive procedure in a body cavity that is normally free of microorganisms.
, NSE 211 Final Exam – Study Guide & Practice Questions
ex; of surgical asepsis procedures - (answer)- protective clothing
- opening sterile packages
- sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis - (answer)- *a sterile object remains sterile only when touched by another
sterile object*
- a sterile object or field out of range of vision or an object held below a person's waist is contaminated
- a sterile objective or field becomes contaminated by prolonged exposure to air.
complications of wound healing - (answer)hemorrhage, infection, dehiscence, evisceration, fistula
formation
hemorrhage nsg dx d/t - (answer)slipped suture, dislodged clot, infection, or eroded blood vessel
hemorrhage nsg dx manifested by - (answer)- external-saturated sanguinous dressings
- internal-distension of body part
- change in drain output
- signs of hypovolemic shock
infection nsg dx d/t - (answer)- exposure to bacteria, contaminated or trauma wound shows S&S,
surgical post-op infection.
infection nsg dx manifested by - (answer)fever, tenderness, pain @ wound site, erythema, edema,
induration, warmth, elevated WBC, inflamed edges, foul odor, purulent drainage, delayed healing
wound - (answer)break in the continuity of body structure, caused by violence, trauma, or surgery to
tissue bodies
ex; of acute wounds - (answer)surgical incisions, traumatic wounds, lacerations, burns
ex; of chronic wounds - (answer)PI, diabetic ulcers, malignant
acute wound - (answer)wound that proceeds through an orderly & timely reparative process -->
sustained restoration of anatomical & functional integrity
phases of wound healing - (answer)1) inflammatory phase
2) proliferative phase
3) remodelling phase
what's a part of the proliferative phase? - (answer)proliferation, granulation & contraction
what happens during inflammatory phase? - (answer)1) hemostasis. (vasoconstriction)
2) platelets + fibrin forms, clot formation
3) histamina, vasodilation, increased capillary permeability, erythema, swelling & warmth
what happens day 1-3 inflammatory phase? - (answer)neutrophils released to injury site, phagocytosis
of debris beings.
what happens during day 3-24 of proliferative phase? - (answer)1) granulation tissue appears in wound
2) contraction of wound edges
3) resurfacing by epithelialization --> dermal regen.
4) vascular bed reestablished
,NSE 211 Final Exam – Study Guide & Practice Questions
what happens during day 24-2 yrs of remodelling phase? - (answer)1) collagen fibers reorganize &
remodel
2) permanent scar
3) attains 80% of original strength
Primary intention healing - (answer)wound that is closed by suture or wound closers & healing occurs by
collagen synthesis; lower risk of infection, and heals quickly w/ minimal scarring.
secondary intention healing - (answer)wound edges are not approximated. heals by granulation tissue
formation, wound contraction & epithelialization.
has a prolonged phase of inflammation due to increased time needed for phagocytosis of necrotic
tissue.
tertiary intention healing - (answer)wound is left open for several days as it could be contaminated. has
an increased risk of infection, so closure of wound is done later until risk of infection is resolved.
why is the wound kept open for tertiary healing? - (answer)to allow exudate to drain, prevent the
spread of deep infection & aiding granulation.
medical asepsis - (answer)aka, *clean technique*.
includes procedures used to reduce & prevent the spread of microorganisms
ex; of medical asepsis - (answer)hand washing, clean gloves, cleaning environment routinely.
ex; of surgical asepsis - (answer)aka *surgical technique*.
requires more stringent techniques, *eliminating all microorganisms*.
when do you use surgical asepsis? - (answer)when a patient's kin is broken, or if the nurse performs an
invasive procedure in a body cavity that is normally free of microorganisms.
, NSE 211 Final Exam – Study Guide & Practice Questions
ex; of surgical asepsis procedures - (answer)- protective clothing
- opening sterile packages
- sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis - (answer)- *a sterile object remains sterile only when touched by another
sterile object*
- a sterile object or field out of range of vision or an object held below a person's waist is contaminated
- a sterile objective or field becomes contaminated by prolonged exposure to air.
complications of wound healing - (answer)hemorrhage, infection, dehiscence, evisceration, fistula
formation
hemorrhage nsg dx d/t - (answer)slipped suture, dislodged clot, infection, or eroded blood vessel
hemorrhage nsg dx manifested by - (answer)- external-saturated sanguinous dressings
- internal-distension of body part
- change in drain output
- signs of hypovolemic shock
infection nsg dx d/t - (answer)- exposure to bacteria, contaminated or trauma wound shows S&S,
surgical post-op infection.
infection nsg dx manifested by - (answer)fever, tenderness, pain @ wound site, erythema, edema,
induration, warmth, elevated WBC, inflamed edges, foul odor, purulent drainage, delayed healing
