NSG 3130 EXAM 2 STUDY SHEET SOLVED
QUESTIONS AND VERIFIED RESPONSES
●● How does pressure lead to tissue ischemia?
Answer: If pressure applied over a capillary exceeds normal capillary
pressure and the vessel is occluded for a prolonged time
●● What occurs is tissue ischemia is left untreated?
Answer: tissue death
●● Does blanching occur in dark skinned patients?
Answer: No, blanching does not occur but color, texture and temp may
differ from surrounding area
●● What does pressure duration assess?
Answer: Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue
death
●● What is tissue tolerance?
Answer: the ability of tissue to endure pressure which is dependent on
the integrity of the tissue and supporting structures
,●● What are risk factors of pressure injuries?
Answer: ◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
●● What should the nurse look for when assessing a pressure injury?
Answer: Wound location, staging, type and approximate percentage of
tissue in wound bed, wound dimensions (sinus tracts and tunneling),
exudate description and condition of surrounding skin
●● stage 1 pressure injury
Answer: Intact skin with nonblanchable redness
●● stage 2 pressure injury
Answer: partial thickness skin loss involving epidermis, dermis or both
and, shallow abrasion or open blister looking
●● stage 3 pressure injury
Answer: full thickness skin loss extending to SQ, crater looking
,●● stage 4 pressure injury
Answer: full thickness with exposed bone, muscle or tendon and may
have eschar
●● What characteristics does stage 3 and 4 pressure injuries share?
Answer: They may have slough, undermining and tunneling present
●● A nurse states slough is present in a stage 3 pressure injury. What
should the student nurse expect to see?
Answer: A yellow or white, stringy substance attached to wound bed
●● A nurse states eschar is present in a stage 4 pressure injury. What
should the student nurse expect to see?
Answer: brown or black necrotic tissue
●● Unstageable/Unclassified Pressure Ulcer
Answer: Tissue loss but depth unknown because wound bed is obscured
by slough and/or eschar
●● A patient has an unstageable pressure ulcer but refuses treatment and
states "it will heal on its own". What education should the nurse
provide?
, Answer: Slough and eschar must be removed by a clinician to determine
the stage and in order for healing to occur
●● suspected 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. Depth unknown
●● A nurse is assessing a wound and notes the presence of granulation
tissue. What should the student nurse expect to see?
Answer: Red, moist tissue which indicates progression toward healing
●● What should the nurse document when assessing exudate?
Answer: Amount, color, consistency and odor
●● The student nurse sees an excess amount of exudate in the wound
bed. What does this indicate?
Answer: The presence of infection
●● What should the nurse look for when assessing the periwound area?
Why is it important?
Answer: Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
QUESTIONS AND VERIFIED RESPONSES
●● How does pressure lead to tissue ischemia?
Answer: If pressure applied over a capillary exceeds normal capillary
pressure and the vessel is occluded for a prolonged time
●● What occurs is tissue ischemia is left untreated?
Answer: tissue death
●● Does blanching occur in dark skinned patients?
Answer: No, blanching does not occur but color, texture and temp may
differ from surrounding area
●● What does pressure duration assess?
Answer: Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue
death
●● What is tissue tolerance?
Answer: the ability of tissue to endure pressure which is dependent on
the integrity of the tissue and supporting structures
,●● What are risk factors of pressure injuries?
Answer: ◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
●● What should the nurse look for when assessing a pressure injury?
Answer: Wound location, staging, type and approximate percentage of
tissue in wound bed, wound dimensions (sinus tracts and tunneling),
exudate description and condition of surrounding skin
●● stage 1 pressure injury
Answer: Intact skin with nonblanchable redness
●● stage 2 pressure injury
Answer: partial thickness skin loss involving epidermis, dermis or both
and, shallow abrasion or open blister looking
●● stage 3 pressure injury
Answer: full thickness skin loss extending to SQ, crater looking
,●● stage 4 pressure injury
Answer: full thickness with exposed bone, muscle or tendon and may
have eschar
●● What characteristics does stage 3 and 4 pressure injuries share?
Answer: They may have slough, undermining and tunneling present
●● A nurse states slough is present in a stage 3 pressure injury. What
should the student nurse expect to see?
Answer: A yellow or white, stringy substance attached to wound bed
●● A nurse states eschar is present in a stage 4 pressure injury. What
should the student nurse expect to see?
Answer: brown or black necrotic tissue
●● Unstageable/Unclassified Pressure Ulcer
Answer: Tissue loss but depth unknown because wound bed is obscured
by slough and/or eschar
●● A patient has an unstageable pressure ulcer but refuses treatment and
states "it will heal on its own". What education should the nurse
provide?
, Answer: Slough and eschar must be removed by a clinician to determine
the stage and in order for healing to occur
●● suspected 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. Depth unknown
●● A nurse is assessing a wound and notes the presence of granulation
tissue. What should the student nurse expect to see?
Answer: Red, moist tissue which indicates progression toward healing
●● What should the nurse document when assessing exudate?
Answer: Amount, color, consistency and odor
●● The student nurse sees an excess amount of exudate in the wound
bed. What does this indicate?
Answer: The presence of infection
●● What should the nurse look for when assessing the periwound area?
Why is it important?
Answer: Redness, warmth, signs of maceration and pain
- presence of any of these factors indicates wound deterioration
