Nurs 323 Final Exam UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
Wound classification factors - CORRECT ANSWER Onset, duration (acute vs chronic), skin
integrity, cause, severity of tissue damage, descriptive qualities - used to categorize a wound
Primary intention healing - CORRECT ANSWER Wound closure with little tissue loss and
edges that are approximated (brought together), e.g. a surgical incision - heals faster, less scarring
Secondary intention healing - CORRECT ANSWER Wound left open to heal from the bottom
up (e.g. burn, stage 2+ pressure injury, severe laceration) - forms scar tissue, higher infection risk
Dehiscence - CORRECT ANSWER Partial or total separation of wound layers; a surgical
incision fails to hold together
Evisceration - CORRECT ANSWER Total separation of wound layers with visceral organs
protruding through the wound - emergency
Wound hemorrhage - CORRECT ANSWER Bleeding complication of healing, caused by
trauma or a dislodged surgical suture
Wound infection/colonization - CORRECT ANSWER All wounds are colonized with bacteria;
culture is taken before starting antibiotics; managed with swabbing, cleaning/irrigation, and topical or
systemic antibiotics
Debridement - CORRECT ANSWER Removal of dead/necrotic tissue from a wound to
promote healing
Moisture balance - CORRECT ANSWER Goal of keeping a wound bed moist but not too wet -
ranges from eschar/dry wound to "just right" to macerated (over-moist) edges
Wound assessment components - CORRECT ANSWER Size, appearance, drain site/drainage
volume and type/suction, dressing type, palpation, wound closures, psychosocial impact
,Wound patient education - CORRECT ANSWER Cleaning and dressing changes, signs of
infection to watch for, when to call the provider (bleeding, infection signs), aseptic care technique
Serous drainage - CORRECT ANSWER Clear, watery wound drainage
Sanguineous drainage - CORRECT ANSWER Bright red, bloody wound drainage
Serosanguineous drainage - CORRECT ANSWER Pink, watery, blood-tinged wound drainage
Purulent drainage - CORRECT ANSWER Thick, yellow/green/brown wound drainage - sign
of infection
Penrose drain - CORRECT ANSWER Open, passive drain that allows fluid to drain via
gravity/capillary action onto a dressing
Jackson-Pratt (JP) drain - CORRECT ANSWER Closed, active suction drain with a bulb;
output must be measured and recorded
Hemovac drain - CORRECT ANSWER Closed, active suction drain with a spring-loaded
chamber; output must be measured and recorded
Gauze (Kerlix) dressing - CORRECT ANSWER Basic woven dressing used to cover/pack
wounds
Transparent film dressing (Tegaderm) - CORRECT ANSWER Clear adhesive dressing that lets
you visualize the wound while protecting it
Hydrocolloid dressing - CORRECT ANSWER Dressing that forms a gel as it absorbs drainage,
keeps a moist healing environment
Foam dressing - CORRECT ANSWER Absorbent dressing used for wounds with moderate to
heavy drainage
, Hydrogel dressing - CORRECT ANSWER Water-based dressing used to add moisture to dry
wounds
Alginate dressing - CORRECT ANSWER Seaweed-derived, highly absorbent dressing used for
heavy drainage or bleeding wounds
Wound VAC (vacuum-assisted closure) - CORRECT ANSWER Negative-pressure device
applied to a wound to remove fluid and promote healing
Wound packing - CORRECT ANSWER Filling a wound cavity with dressing material to keep
it open for healing - do not overpack
Stage 1 pressure injury - CORRECT ANSWER Intact skin with localized, non-blanchable
erythema (redness that doesn't turn white when pressed)
Stage 2 pressure injury - CORRECT ANSWER Partial thickness skin loss with exposed viable
dermis - pink/red, moist wound bed, may have an intact or ruptured blister
Stage 3 pressure injury - CORRECT ANSWER Full thickness skin loss with visible adipose
(fat) and granulation tissue; rolled wound edges (epibole); slough/eschar may be visible, but
bone/muscle/tendon are NOT exposed
Stage 4 pressure injury - CORRECT ANSWER Full thickness skin loss with exposed/palpable
fascia, muscle, tendon, ligament, cartilage, or bone; often has tunneling
Unstageable pressure injury - CORRECT ANSWER Full thickness loss where the wound base
is covered by slough or a stable, dry, adherent eschar, hiding the true stage
Deep tissue pressure injury (DTPI) - CORRECT ANSWER Intact or non-intact skin with a
localized, non-blanchable area that is deep red/maroon/purple - caused by prolonged pressure or shear
Right medication (7 rights) - CORRECT ANSWER Verify the drug ordered matches the drug
being given
QUESTIONS AND CORRECT ANSWERS
Wound classification factors - CORRECT ANSWER Onset, duration (acute vs chronic), skin
integrity, cause, severity of tissue damage, descriptive qualities - used to categorize a wound
Primary intention healing - CORRECT ANSWER Wound closure with little tissue loss and
edges that are approximated (brought together), e.g. a surgical incision - heals faster, less scarring
Secondary intention healing - CORRECT ANSWER Wound left open to heal from the bottom
up (e.g. burn, stage 2+ pressure injury, severe laceration) - forms scar tissue, higher infection risk
Dehiscence - CORRECT ANSWER Partial or total separation of wound layers; a surgical
incision fails to hold together
Evisceration - CORRECT ANSWER Total separation of wound layers with visceral organs
protruding through the wound - emergency
Wound hemorrhage - CORRECT ANSWER Bleeding complication of healing, caused by
trauma or a dislodged surgical suture
Wound infection/colonization - CORRECT ANSWER All wounds are colonized with bacteria;
culture is taken before starting antibiotics; managed with swabbing, cleaning/irrigation, and topical or
systemic antibiotics
Debridement - CORRECT ANSWER Removal of dead/necrotic tissue from a wound to
promote healing
Moisture balance - CORRECT ANSWER Goal of keeping a wound bed moist but not too wet -
ranges from eschar/dry wound to "just right" to macerated (over-moist) edges
Wound assessment components - CORRECT ANSWER Size, appearance, drain site/drainage
volume and type/suction, dressing type, palpation, wound closures, psychosocial impact
,Wound patient education - CORRECT ANSWER Cleaning and dressing changes, signs of
infection to watch for, when to call the provider (bleeding, infection signs), aseptic care technique
Serous drainage - CORRECT ANSWER Clear, watery wound drainage
Sanguineous drainage - CORRECT ANSWER Bright red, bloody wound drainage
Serosanguineous drainage - CORRECT ANSWER Pink, watery, blood-tinged wound drainage
Purulent drainage - CORRECT ANSWER Thick, yellow/green/brown wound drainage - sign
of infection
Penrose drain - CORRECT ANSWER Open, passive drain that allows fluid to drain via
gravity/capillary action onto a dressing
Jackson-Pratt (JP) drain - CORRECT ANSWER Closed, active suction drain with a bulb;
output must be measured and recorded
Hemovac drain - CORRECT ANSWER Closed, active suction drain with a spring-loaded
chamber; output must be measured and recorded
Gauze (Kerlix) dressing - CORRECT ANSWER Basic woven dressing used to cover/pack
wounds
Transparent film dressing (Tegaderm) - CORRECT ANSWER Clear adhesive dressing that lets
you visualize the wound while protecting it
Hydrocolloid dressing - CORRECT ANSWER Dressing that forms a gel as it absorbs drainage,
keeps a moist healing environment
Foam dressing - CORRECT ANSWER Absorbent dressing used for wounds with moderate to
heavy drainage
, Hydrogel dressing - CORRECT ANSWER Water-based dressing used to add moisture to dry
wounds
Alginate dressing - CORRECT ANSWER Seaweed-derived, highly absorbent dressing used for
heavy drainage or bleeding wounds
Wound VAC (vacuum-assisted closure) - CORRECT ANSWER Negative-pressure device
applied to a wound to remove fluid and promote healing
Wound packing - CORRECT ANSWER Filling a wound cavity with dressing material to keep
it open for healing - do not overpack
Stage 1 pressure injury - CORRECT ANSWER Intact skin with localized, non-blanchable
erythema (redness that doesn't turn white when pressed)
Stage 2 pressure injury - CORRECT ANSWER Partial thickness skin loss with exposed viable
dermis - pink/red, moist wound bed, may have an intact or ruptured blister
Stage 3 pressure injury - CORRECT ANSWER Full thickness skin loss with visible adipose
(fat) and granulation tissue; rolled wound edges (epibole); slough/eschar may be visible, but
bone/muscle/tendon are NOT exposed
Stage 4 pressure injury - CORRECT ANSWER Full thickness skin loss with exposed/palpable
fascia, muscle, tendon, ligament, cartilage, or bone; often has tunneling
Unstageable pressure injury - CORRECT ANSWER Full thickness loss where the wound base
is covered by slough or a stable, dry, adherent eschar, hiding the true stage
Deep tissue pressure injury (DTPI) - CORRECT ANSWER Intact or non-intact skin with a
localized, non-blanchable area that is deep red/maroon/purple - caused by prolonged pressure or shear
Right medication (7 rights) - CORRECT ANSWER Verify the drug ordered matches the drug
being given
