Nclex Uworld Review Questions And
Answers
Stage 1 pressure ulcer non-blanchable intact skin with localized redness
Stage 2 pressure ulcer open, shallow ulcer with red-pink wound based w/o sloughing. it
may have an intact or ruptured blister
Stage 3 pressure ulcer full thickness skin loss with possible exposed subcutaneous tissue.
there is no visible muscle, tendon or bone exposure
Stage 4 ulcer full thickness skin loss with visible bone, muscle or tendon
Unstageable full thickness skin loss and the ulcer base is covered with eschar and/or
slough that needs to be removed for staging
Signs of abuse in children -SBS (irritability or lethargy, poor feeding, emesis, seizures)
-burns from common household objects, from cigs, or from immersion in scolding liquid
-injuries in various phases of healing
-injuries to genitals
, Nclex Uworld Review Questions And
Answers
-lapsed time from the injury to when they sought care
-inconsistencies with injury and caregiver story
-long bone fractures of humerus and femur; retinal hemorrhage; frenulum tears or gingival
lesions; subdural or epidural hematoma
Vaso-occlusive crisis primary treatment is high flow IV fluids, once the patient is hydrated
then apply supplemental oxygen.
-w/o hydration the sickled cells are unable to carry oxygen so supplemental oxygen will not do
anything
TED stockings -measure from the heel to the popliteal and the circumference of the calf at
the widest point
-ensure there are no rolls, wrinkles or folds bc they can have a tourniquet affect
-cover discrete wounds with an occlusive dressing before apply TED stockings
-worn 24/7
Colostomy care colostomy appliances are changed every 5-10 days, if the appliances and
bags are changed too frequently it can cause skin irritation
Answers
Stage 1 pressure ulcer non-blanchable intact skin with localized redness
Stage 2 pressure ulcer open, shallow ulcer with red-pink wound based w/o sloughing. it
may have an intact or ruptured blister
Stage 3 pressure ulcer full thickness skin loss with possible exposed subcutaneous tissue.
there is no visible muscle, tendon or bone exposure
Stage 4 ulcer full thickness skin loss with visible bone, muscle or tendon
Unstageable full thickness skin loss and the ulcer base is covered with eschar and/or
slough that needs to be removed for staging
Signs of abuse in children -SBS (irritability or lethargy, poor feeding, emesis, seizures)
-burns from common household objects, from cigs, or from immersion in scolding liquid
-injuries in various phases of healing
-injuries to genitals
, Nclex Uworld Review Questions And
Answers
-lapsed time from the injury to when they sought care
-inconsistencies with injury and caregiver story
-long bone fractures of humerus and femur; retinal hemorrhage; frenulum tears or gingival
lesions; subdural or epidural hematoma
Vaso-occlusive crisis primary treatment is high flow IV fluids, once the patient is hydrated
then apply supplemental oxygen.
-w/o hydration the sickled cells are unable to carry oxygen so supplemental oxygen will not do
anything
TED stockings -measure from the heel to the popliteal and the circumference of the calf at
the widest point
-ensure there are no rolls, wrinkles or folds bc they can have a tourniquet affect
-cover discrete wounds with an occlusive dressing before apply TED stockings
-worn 24/7
Colostomy care colostomy appliances are changed every 5-10 days, if the appliances and
bags are changed too frequently it can cause skin irritation
