NUR155 Exam 3 Review Questions and Answers | 100% Success

NUR155 Exam 3 Review Questions and Answers | 100% Success Patients at risk for wounds - Answer ️️ -Heart and lung disease, diabetes, malnourishment and nutritional deficit Signs of an infected wound - Answer ️️ -Increased fever, redness, edema, drainage (not always), warmth, positive bacteria growth on culture Primary intention - Answer ️️ -Well approximated. Surgical incision with sutures or staples Secondary intention - Answer ️️ -Tunnels or fistula, gaping hole. Must be packed with wet-to- dry. Big risk for infection Tertiary - Answer ️️ -Delayed primary intention. Started off well approximated, but now opening at the end 1st phase of healing - Answer ️️ -Inflammatory. Coagulation cascade- clotting to stop bleeding 2nd phase of healing - Answer ️️ -Proliferative phase. Granulation tissue- bumpy, pink, beefy red tissue 3rd phase of healing - Answer ️️ -Maturation phase. Scar tissue, body needs a high protein diet and vitamin C Sanguineous - Answer ️️ -Bloody drainage Serosanguineous - Answer ️️ -Pale, red, watery: mixture of clear and red fluid Serous - Answer ️️ -clear, watery plasma Purulent - Answer ️️ -Thick, green or yellow tinged, pus Purosanguineous - Answer ️️ -yellowish-red, pus and blood present, new infected wound Hemorrhage - Answer ️️ -Increased sanguineous bleeding Nursing interventions: 1. Vitals, SpO2 below 95%, 2. Head to toe assessment, 3. Labs (CBC, culture and sensitivity, blood culture and sensitivity) Stage 1 Pressure Injury - Answer ️️ -Intact skin, non-blanchable, partial thickness. Redness, edema, ecchymosis Nursing interventions: Assess for blanching, turn patient off area, pressure injury interventions Stage 2 Pressure Injury - Answer ️️ -Epidermis and dermis is gone, skin tear, open wound, partial thickness, redness, ecchymosis, edema, drainage, non-approximated Stage 3 Pressure Injury - Answer ️️ -Crater-like, epidermis, dermis and sub q layers gone. Leading into muscle area. Could have a fistula or tunneling. Infection risk. Full thickness Stage 4 Pressure Injury - Answer ️️ -Can have fistula/tunneling. Epidermis, dermis, sub q, muscle gone, bone is exposed. Infection risk. Full thickness Stage 5 Pressure Injury - Answer ️️ -Unstageable. Blackened eschar (dead skin cells). Black, green, yellow. Nursing interventions: debriding Types of debriding - Answer ️️ -Mechanical- wet-to-dry dressing Surgical- removed by scalpel performed by MD Chemical- chemical base added to the wound, eats bacteria Biological- adds green bottle flies, insects to wounds Autolytic- add a dressing that will enclose wound and the body will use its enzymes to destroy bacteria and regenerates tissue Types of dressings - Answer ️️ -Gauze: absorbing (mechanical/debridement) -use on sta