NSG-300 Exam 2 Questions With Complete
Solutions
what places patients at risk for pressure ulcers/impaired skin integrity - ANSWER-
pressure intensity, pressure duration, tissue tolerance, impaired sensory
perception, impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin - ANSWER-epidermis, dermis (collagen)
body's defenses against infection - ANSWER-normal flora, inflammatory response,
immune response
comprehensive wound assessment - ANSWER--ongoing assessment from time of
injury, wound care, any condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description,
response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - ANSWER-assesses risk for developing pressure ulcers; includes
patient's sensory perception, moisture, activity, mobility, nutrition, friction and
shear; the lower the number the higher the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
,15-18= mild risk
19-23= generally not at risk
type 1 ulcers - ANSWER-skin is intact but may be red or pink and warm to the
touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - ANSWER-partial-thickness loss of dermis; shallow broken skin; red-
pink wound bed
type 3 ulcers - ANSWER-full-thickness tissue loss with visible fat (subcutaneous
layer); pale-yellow color; may include slough but does not obstruct view of depth
of injury
type 4 ulcers - ANSWER-full-thickness tissue loss with exposed bone, muscle, or
tendon. possible tunneling and undermining
unstageable pressure ulcer - ANSWER-base of ulcer covered by slough and/or
eschar in the wound bed so the depth is unknown; exudate;
deep tissue injury - ANSWER-Purple or maroon localized area of discolored intact
skin or blood-filled blister due to damage of underlying soft tissue from pressure
and/or shear.
how should you clean a wound - ANSWER-from least to most contaminated
,eschar - ANSWER-black, brown or necrotic tissue in wound bed; needs to be
removed before healing
slough - ANSWER-stringy pale-yellowish tissue that lays in the wound bed; needs
to be removed before healing
if a patient has slough, eschar, and infectious exudate which one would you be
most concerned about - ANSWER-infectious exudate
factors influencing heat and cold tolerance - ANSWER-Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - ANSWER-location, staging (depth), type
and % of tissue in wound bed, wound dimensions (including tunneling), exudate
description (if odor is present), and condition of surrounding skin
why is depth of an ulcer important - ANSWER-because the wound heals inside-out
granulation tissue - ANSWER-good, fresh tissue that forms during the healing of a
wound (wound bed will be red, moist, and shiny)
, How does a partial thickness wound heal? - ANSWER-by regeneration (scratch or
abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate.
1st 24hrs after wounding.
-epithelial proliferation (reproduction): starts at wound edges and epidermal cells
lining appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry
wound, the cells move down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and
appear as dry, pink tissue
How does a full thickness wound heal? - ANSWER-by forming new tissue/scar
formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of
surrounding capillaries and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is
filled with replacement tissue (collagen, contraction, and granulation tissue), and
the surface is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for
several months. Collagen fibers undergo remodeling or reorganization before
assuming their normal appearance
primary intention - ANSWER-wound that is closed/approximated; little tissue loss;
low risk of infection; quick healing with no scar usually (surgical incision)
Solutions
what places patients at risk for pressure ulcers/impaired skin integrity - ANSWER-
pressure intensity, pressure duration, tissue tolerance, impaired sensory
perception, impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin - ANSWER-epidermis, dermis (collagen)
body's defenses against infection - ANSWER-normal flora, inflammatory response,
immune response
comprehensive wound assessment - ANSWER--ongoing assessment from time of
injury, wound care, any condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description,
response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - ANSWER-assesses risk for developing pressure ulcers; includes
patient's sensory perception, moisture, activity, mobility, nutrition, friction and
shear; the lower the number the higher the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
,15-18= mild risk
19-23= generally not at risk
type 1 ulcers - ANSWER-skin is intact but may be red or pink and warm to the
touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - ANSWER-partial-thickness loss of dermis; shallow broken skin; red-
pink wound bed
type 3 ulcers - ANSWER-full-thickness tissue loss with visible fat (subcutaneous
layer); pale-yellow color; may include slough but does not obstruct view of depth
of injury
type 4 ulcers - ANSWER-full-thickness tissue loss with exposed bone, muscle, or
tendon. possible tunneling and undermining
unstageable pressure ulcer - ANSWER-base of ulcer covered by slough and/or
eschar in the wound bed so the depth is unknown; exudate;
deep tissue injury - ANSWER-Purple or maroon localized area of discolored intact
skin or blood-filled blister due to damage of underlying soft tissue from pressure
and/or shear.
how should you clean a wound - ANSWER-from least to most contaminated
,eschar - ANSWER-black, brown or necrotic tissue in wound bed; needs to be
removed before healing
slough - ANSWER-stringy pale-yellowish tissue that lays in the wound bed; needs
to be removed before healing
if a patient has slough, eschar, and infectious exudate which one would you be
most concerned about - ANSWER-infectious exudate
factors influencing heat and cold tolerance - ANSWER-Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - ANSWER-location, staging (depth), type
and % of tissue in wound bed, wound dimensions (including tunneling), exudate
description (if odor is present), and condition of surrounding skin
why is depth of an ulcer important - ANSWER-because the wound heals inside-out
granulation tissue - ANSWER-good, fresh tissue that forms during the healing of a
wound (wound bed will be red, moist, and shiny)
, How does a partial thickness wound heal? - ANSWER-by regeneration (scratch or
abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate.
1st 24hrs after wounding.
-epithelial proliferation (reproduction): starts at wound edges and epidermal cells
lining appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry
wound, the cells move down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and
appear as dry, pink tissue
How does a full thickness wound heal? - ANSWER-by forming new tissue/scar
formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of
surrounding capillaries and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is
filled with replacement tissue (collagen, contraction, and granulation tissue), and
the surface is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for
several months. Collagen fibers undergo remodeling or reorganization before
assuming their normal appearance
primary intention - ANSWER-wound that is closed/approximated; little tissue loss;
low risk of infection; quick healing with no scar usually (surgical incision)
