NR224 Fundamentals Skills Final Exam
Review Latest Updated 2025 With
Complete Solutions
Healing process - ANSWERS-Primary Intention: Wound that is closed
Secondary Intention: Wound edges not approximated
Tertiary Intention: Wound that is left open for several days; then wo approximated
Desiccation - ANSWERS-drying out
Maceration - ANSWERS-Softening or breaking down the skin due to exposure to
moisture
Pressure - ANSWERS-"pressure" areas of the skin that are more at risk for breakdown
Trauma - ANSWERS-caused by physical harm to the area
Edema - ANSWERS-swelling
Necrosis - ANSWERS-tissue death in area slows other tissue healing
Hemorrhage - ANSWERS--bleeding
-May be seen externally, or may be internal and careful assessment needed to assess
Dehiscence - ANSWERS-Incision fails to heal properly, or tissues separate
Evisceration - ANSWERS-Protrusion of visceral organs through a surgical wo
Stages of pressure injuries - ANSWERS-Stage I — nonblanchable erythema of intact
skin
Stage II — partial-thickness skin loss
Stage III — full-thickness tissue loss; SC fat is visible
Stage IV — full-thickness tissue loss with extensive destruction. Exposed bone, tendon
or muscle.
Deep-Tissue Pressure Injury- persistent non-blanchable deep discoloration of red,
maroon, purple
Unstageable Pressure Injury- obscured full thickness loss
Assessing a wound and documenting the wound - ANSWERS--Tissue types:
•granulation, necrotic, eschar, slough
-Drainage types:
, •Serous- clear, thin, plasma
•Sanguineous- blood, active bleeding, presence of RBC
•Serosanguineous- combination of serous and sanguineous, color will be darker to
lighter pink
•Purulent- think, opaque, yellowish, brown, tan, green; NEVER GOOD!
-Measurements:
•Length (L)x Width (W) x Depth (D)
-Client tolerance
-Type of dressing
Wounds healing by secondary intention - ANSWERS-A. Stage III pressure injury
E. Open burn area
Wound healing by primary intention - ANSWERS-Cut in the skin from a kitchen knife
Infected wound indication - ANSWERS-A. it has no odor.
Purulent drainage - ANSWERS-It shows purulent drainage coming from the incision
site.
Mobility systems - ANSWERS-Musculoskeletal & Neurological.
Respiratory immobility interventions - ANSWERS--Deep breathing and coughing
-Incentive spirometer
-Positioning changes
-Oxygen therapy
-Chest physiotherapy (Chest PT)
-Suctioning
-Hydration (oral or IV fluids)
Cardiovascular immobility interventions - ANSWERS--Anti-embolitic Stockings (TED
hose)
-Change position q2hr
-Anticoagulants (heparin, Lovenox, etc.)
-Dangle patient when sitting or prior to standing
Musculoskeletal immobility interventions - ANSWERS--Active and passive ROM
-Isometric exercises
-Physical therapy
-Braces & supports to prevent foot drop and contractures
-Use of assistive devices
-Positioning
Integumentary immobility interventions - ANSWERS--Frequent skin assessments
-Turn client q2hr
-Use therapeutic bed or mattress
Review Latest Updated 2025 With
Complete Solutions
Healing process - ANSWERS-Primary Intention: Wound that is closed
Secondary Intention: Wound edges not approximated
Tertiary Intention: Wound that is left open for several days; then wo approximated
Desiccation - ANSWERS-drying out
Maceration - ANSWERS-Softening or breaking down the skin due to exposure to
moisture
Pressure - ANSWERS-"pressure" areas of the skin that are more at risk for breakdown
Trauma - ANSWERS-caused by physical harm to the area
Edema - ANSWERS-swelling
Necrosis - ANSWERS-tissue death in area slows other tissue healing
Hemorrhage - ANSWERS--bleeding
-May be seen externally, or may be internal and careful assessment needed to assess
Dehiscence - ANSWERS-Incision fails to heal properly, or tissues separate
Evisceration - ANSWERS-Protrusion of visceral organs through a surgical wo
Stages of pressure injuries - ANSWERS-Stage I — nonblanchable erythema of intact
skin
Stage II — partial-thickness skin loss
Stage III — full-thickness tissue loss; SC fat is visible
Stage IV — full-thickness tissue loss with extensive destruction. Exposed bone, tendon
or muscle.
Deep-Tissue Pressure Injury- persistent non-blanchable deep discoloration of red,
maroon, purple
Unstageable Pressure Injury- obscured full thickness loss
Assessing a wound and documenting the wound - ANSWERS--Tissue types:
•granulation, necrotic, eschar, slough
-Drainage types:
, •Serous- clear, thin, plasma
•Sanguineous- blood, active bleeding, presence of RBC
•Serosanguineous- combination of serous and sanguineous, color will be darker to
lighter pink
•Purulent- think, opaque, yellowish, brown, tan, green; NEVER GOOD!
-Measurements:
•Length (L)x Width (W) x Depth (D)
-Client tolerance
-Type of dressing
Wounds healing by secondary intention - ANSWERS-A. Stage III pressure injury
E. Open burn area
Wound healing by primary intention - ANSWERS-Cut in the skin from a kitchen knife
Infected wound indication - ANSWERS-A. it has no odor.
Purulent drainage - ANSWERS-It shows purulent drainage coming from the incision
site.
Mobility systems - ANSWERS-Musculoskeletal & Neurological.
Respiratory immobility interventions - ANSWERS--Deep breathing and coughing
-Incentive spirometer
-Positioning changes
-Oxygen therapy
-Chest physiotherapy (Chest PT)
-Suctioning
-Hydration (oral or IV fluids)
Cardiovascular immobility interventions - ANSWERS--Anti-embolitic Stockings (TED
hose)
-Change position q2hr
-Anticoagulants (heparin, Lovenox, etc.)
-Dangle patient when sitting or prior to standing
Musculoskeletal immobility interventions - ANSWERS--Active and passive ROM
-Isometric exercises
-Physical therapy
-Braces & supports to prevent foot drop and contractures
-Use of assistive devices
-Positioning
Integumentary immobility interventions - ANSWERS--Frequent skin assessments
-Turn client q2hr
-Use therapeutic bed or mattress
