NSG-300 Exam 2 Questions with Verified
Correct Answers
what places patients at risk for pressure ulcers/impaired skin integrity
pressure intensity, pressure duration, tissue tolerance, impaired sensory perception, impaired
mobility, alteration in LOC, shear, friction, moisture
layers of the skin
epidermis, dermis (collagen)
body's defenses against infection
normal flora, inflammatory response, immune response
comprehensive wound assessment
-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
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
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
partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers
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
full-thickness tissue loss with exposed bone, muscle, or tendon. possible tunneling and
undermining
unstageable pressure ulcer
base of ulcer covered by slough and/or eschar in the wound bed so the depth is unknown;
exudate;
deep tissue injury
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
from least to most contaminated
, eschar
black, brown or necrotic tissue in wound bed; needs to be removed before healing
slough
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
infectious exudate
factors influencing heat and cold tolerance
Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes
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
because the wound heals inside-out
granulation tissue
good, fresh tissue that forms during the healing of a wound (wound bed will be red, moist,
and shiny)
Correct Answers
what places patients at risk for pressure ulcers/impaired skin integrity
pressure intensity, pressure duration, tissue tolerance, impaired sensory perception, impaired
mobility, alteration in LOC, shear, friction, moisture
layers of the skin
epidermis, dermis (collagen)
body's defenses against infection
normal flora, inflammatory response, immune response
comprehensive wound assessment
-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
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
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
partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers
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
full-thickness tissue loss with exposed bone, muscle, or tendon. possible tunneling and
undermining
unstageable pressure ulcer
base of ulcer covered by slough and/or eschar in the wound bed so the depth is unknown;
exudate;
deep tissue injury
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
from least to most contaminated
, eschar
black, brown or necrotic tissue in wound bed; needs to be removed before healing
slough
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
infectious exudate
factors influencing heat and cold tolerance
Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes
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
because the wound heals inside-out
granulation tissue
good, fresh tissue that forms during the healing of a wound (wound bed will be red, moist,
and shiny)
