NSG 100 FINAL EXAM | UPDATED ACTUAL QUESTIONS |
COMPLETE STUDY GUIDE AND VERIFIED SOLUTIONS
• Stage 1 pressure ulcer -✓✓ANSWER: intact skin with nonblanchable redness
• stage 2 pressure ulcer -✓✓ANSWER: partial thickness skin loss involving
epidermis, dermis, or both
• stage 3 pressure ulcer -✓✓ANSWER: full thickness skin loss
• stage 4 pressure ulcer -✓✓ANSWER: Full-thickness tissue loss with exposed
bone, muscle, or tendon
• unstageable pressure ulcer -✓✓ANSWER: Full thickness tissue loss in which the
base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or
eschar (tan, brown or black) in the wound bed.
• 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.
• How to prevent falls -✓✓ANSWER: -call bell in reach
-remove clutter
-fall socks (yellow and non-slip)
-bed alarm
-ensure room is well lit
,-offer help tp the bathroom frequently
• chain of infection -✓✓ANSWER: infectious agent, reservoir, portal of exit, mode
of transmission, portal of entry, susceptible host
• infectious agent -✓✓ANSWER: bacteria, viruses, fungi
• Reservoir (chain of infection) -✓✓ANSWER: The place where an infectious agent
(microorganism) can survive.
• portal of exit/entry -✓✓ANSWER: the way in/out (respiratory, GI, urinary tract,
break in skin)
• mode of transmission -✓✓ANSWER: a way that the causative agent can be
transmitted to another reservoir or host where it can live
• susceptible host -✓✓ANSWER: a person likely to get an infection or disease,
usually because body defenses are weak
• Nursing Process -✓✓ANSWER: Assessment
Diagnosis
Planning
Implementation
Evaluation
, • Assessment (nursing process) -✓✓ANSWER: 1- collection of info from primary
source (pt) and secondary (family, friends, health professionals, medical record).
2- interpretation and validation of data to ensure a complete data base
subjective and objective
• subjective data -✓✓ANSWER: things a person tells you about that you cannot
observe through your senses; symptoms
• objective data -✓✓ANSWER: information that is seen, heard, felt, or smelled by
an observer; signs
• Diagnosis (nursing process) -✓✓ANSWER: systematic process of analyzing info,
ending w/ clinical judgement
gives focus and direction for planning
problems that form the basics for your plan of action
strengths used to develop an effective plan of approach
• Planning (nursing process) -✓✓ANSWER: setting priorities, identifying patient-
centered goals and expected outcomes, and prescribing nursing interventions
• Implementation (nursing process) -✓✓ANSWER: - Implement in a safe and
timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
COMPLETE STUDY GUIDE AND VERIFIED SOLUTIONS
• Stage 1 pressure ulcer -✓✓ANSWER: intact skin with nonblanchable redness
• stage 2 pressure ulcer -✓✓ANSWER: partial thickness skin loss involving
epidermis, dermis, or both
• stage 3 pressure ulcer -✓✓ANSWER: full thickness skin loss
• stage 4 pressure ulcer -✓✓ANSWER: Full-thickness tissue loss with exposed
bone, muscle, or tendon
• unstageable pressure ulcer -✓✓ANSWER: Full thickness tissue loss in which the
base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or
eschar (tan, brown or black) in the wound bed.
• 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.
• How to prevent falls -✓✓ANSWER: -call bell in reach
-remove clutter
-fall socks (yellow and non-slip)
-bed alarm
-ensure room is well lit
,-offer help tp the bathroom frequently
• chain of infection -✓✓ANSWER: infectious agent, reservoir, portal of exit, mode
of transmission, portal of entry, susceptible host
• infectious agent -✓✓ANSWER: bacteria, viruses, fungi
• Reservoir (chain of infection) -✓✓ANSWER: The place where an infectious agent
(microorganism) can survive.
• portal of exit/entry -✓✓ANSWER: the way in/out (respiratory, GI, urinary tract,
break in skin)
• mode of transmission -✓✓ANSWER: a way that the causative agent can be
transmitted to another reservoir or host where it can live
• susceptible host -✓✓ANSWER: a person likely to get an infection or disease,
usually because body defenses are weak
• Nursing Process -✓✓ANSWER: Assessment
Diagnosis
Planning
Implementation
Evaluation
, • Assessment (nursing process) -✓✓ANSWER: 1- collection of info from primary
source (pt) and secondary (family, friends, health professionals, medical record).
2- interpretation and validation of data to ensure a complete data base
subjective and objective
• subjective data -✓✓ANSWER: things a person tells you about that you cannot
observe through your senses; symptoms
• objective data -✓✓ANSWER: information that is seen, heard, felt, or smelled by
an observer; signs
• Diagnosis (nursing process) -✓✓ANSWER: systematic process of analyzing info,
ending w/ clinical judgement
gives focus and direction for planning
problems that form the basics for your plan of action
strengths used to develop an effective plan of approach
• Planning (nursing process) -✓✓ANSWER: setting priorities, identifying patient-
centered goals and expected outcomes, and prescribing nursing interventions
• Implementation (nursing process) -✓✓ANSWER: - Implement in a safe and
timely manner
- Use evidence-based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
