WGU D439 FOUNDATIONS OF NURSING OA
88 EXAMPREP QUESTIONS AND DETAILED
SOLUTIONS
◉ restraint tying area.
Answer: BED FRAME ONLY
◉ chemical restraints.
Answer: meds such as benzos
◉ first thing to assess after restraint.
Answer: CAPILLARY REFILL
◉ when to check capillary refill when restrained.
Answer: immediately and every 15 mins
◉ other checks when restrained.
Answer: skin integrity, vital signs, ROM every 2 hours; offer
bathroom every 2 hours
◉ restraint documentation.
,Answer: reasoning, mental status, care offered, time in restraints
◉ restraint order time.
Answer: ONLY last 24 hours
◉ urine specific gravity test use.
Answer: identify dehydration, kidney problems, conditions like
diabetes insipidus
◉ urine specific gravity test & range.
Answer: concentration of particles in urine; 1.005- 1.030
◉ high urine specific gravity test.
Answer: HIGH = YOU'RE DRY/ DEHYDRATED =
VOMITING/DIARRHEA
◉ low urine specific gravity test.
Answer: "overflow" kidney damage, kidney failure
◉ pressure ulcers.
Answer: "1 red, 2 broken, 3 deep, 4 bone"
, red intact skin, break with blister, deep tissue, bone visible
◉ pressure ulcers stage 1.
Answer: red intact skin
◉ pressure ulcers stage 2.
Answer: skin breaks & blisters; 2 layers affected (epidermis, dermis)
◉ pressure ulcers stage 3.
Answer: full thickness skin loss; 3 layers affected (epi, dermis, sub-q
tissue)
◉ pressure ulcers stage 4.
Answer: goes down into muscle and bone; 4 layers
◉ pressure ulcers unstageable.
Answer: eschar (black/brown dead tissue) and slough (yellow and
stringy) make it impossible to see; perform debridement
◉ pressure ulcers deep tissue.
Answer: purple and dead; over bony prominences; thirty degree
lateral inclined position releases pressure
88 EXAMPREP QUESTIONS AND DETAILED
SOLUTIONS
◉ restraint tying area.
Answer: BED FRAME ONLY
◉ chemical restraints.
Answer: meds such as benzos
◉ first thing to assess after restraint.
Answer: CAPILLARY REFILL
◉ when to check capillary refill when restrained.
Answer: immediately and every 15 mins
◉ other checks when restrained.
Answer: skin integrity, vital signs, ROM every 2 hours; offer
bathroom every 2 hours
◉ restraint documentation.
,Answer: reasoning, mental status, care offered, time in restraints
◉ restraint order time.
Answer: ONLY last 24 hours
◉ urine specific gravity test use.
Answer: identify dehydration, kidney problems, conditions like
diabetes insipidus
◉ urine specific gravity test & range.
Answer: concentration of particles in urine; 1.005- 1.030
◉ high urine specific gravity test.
Answer: HIGH = YOU'RE DRY/ DEHYDRATED =
VOMITING/DIARRHEA
◉ low urine specific gravity test.
Answer: "overflow" kidney damage, kidney failure
◉ pressure ulcers.
Answer: "1 red, 2 broken, 3 deep, 4 bone"
, red intact skin, break with blister, deep tissue, bone visible
◉ pressure ulcers stage 1.
Answer: red intact skin
◉ pressure ulcers stage 2.
Answer: skin breaks & blisters; 2 layers affected (epidermis, dermis)
◉ pressure ulcers stage 3.
Answer: full thickness skin loss; 3 layers affected (epi, dermis, sub-q
tissue)
◉ pressure ulcers stage 4.
Answer: goes down into muscle and bone; 4 layers
◉ pressure ulcers unstageable.
Answer: eschar (black/brown dead tissue) and slough (yellow and
stringy) make it impossible to see; perform debridement
◉ pressure ulcers deep tissue.
Answer: purple and dead; over bony prominences; thirty degree
lateral inclined position releases pressure
