FUNDAMENTAL SKILLS EXAM 1
CLINICAL SKILLS QUESTIONS AND
ANSWERS
Safety risk factors (Patient, Procedure, Equipment and Environmental) - Answer--
Mobility, sensory, cognitive status, impaired mobility, lifestyle choices, lack of safety
awareness
-The home they reside in...is it fully handicapped? Is it lacking quality features of
that?
Nursing process to Assess patient safety risk factors, Diagnoses related to risk
factors, Desired Patient Outcomes, Nursing interventions to promote patient safety
and decrease safety risks. - Answer--Assessment: activity/exercise/medication
history/history of falls/home maintenance & safety
-Diagnosis: risk for falls/impaired home maintenance, risk for injury, deficient
knowledge, risk for poisoning, risk for suffocation, risk for trauma
-Planning: goals/outcomes->prevent & minimize safety threats, are
measurable/realistic, ay include active patient participation, setting priorities,
teamwork/collaboration
-Implementation: health promotion/prevention, individualization or implementation
(Developmental stage, lifestyle, environmental), basic needs, acute care safety
(seizures, poisoning, electrical hazards, radiation, disasters)
-Evaluation: "Are the patients expectations met?", monitor outcomes by the
healthcare team and monitor outcome for each diagnosis while continually assessing
for additional support
Louis Blackman - Answer-lessons learned related to nursing care and patient safety.
Patient factors and other factors that impact wound healing. - Answer--Aging skin,
chronic illness, immobility, malnutrition, fecal/urinary incontinence, altered level of
consciousness, spinal cord/brain injuries, neuromuscular disorders
Skin care and functions of skin - Answer--Functions of skin: protection, body
temperature regulation, psychological, sensation, vitamin D production,
immunological, absorption, elimination
Types of wounds/ wound healing intention - Answer--Intentional/unintentional,
open/closed, acute/chronic, partial thickness, full thickness
-First intention: clean incision with primary closure, minimal scarring, approximated
edges
-Second intention: wound is left open so granulation can occur, large scar results, if
infected left open and later closed when there is no evidence of infection
Expected progression of character (what it looks like) of drainage in healing wound -
Answer-Serosanguinous drainage is the most common type of exudate that is seen
, in wounds. It is thin, pink, and watery in presentation. Purulent drainage is milky,
typically thicker in consistency, and can be gray, green, or yellow in appearance.
Wound healing complications - Answer--Infection, hemorrhage, dehiscence,
evisceration
Care of wounds to include (not limited to) wound irrigation/debridement - Answer--
Irrigation: flush/irrigate the ulcer with 0.9% normal saline solution with carefulness.
Use sterile technique with 35mL syringes and 19-gauge needle to remove any
exudate.
-Debridement: Removing necrotic tissue, aka non-selective removal of nonviable
tissue and debris from the wound-by-wound irrigation, hydrotherapy, or wet-to-dry
dressings
Pressure injuries (everything about them, causes, treatments, staging debridement
etc.) it did not talk about debridement in the PowerPoint but that's basically when u
clean out a stage 4 pressure ulcer, so could u find info on that on her page?? -
Answer--Stages: stage I (nonblanchable erythema of intact skin), stage II (partial
thickness skin loss), stage III (full-thickness skin loss; not involving underlying
fascia), stage IV (full thickness skin loss with extensive destruction bone/tendon
exposed, unstageable (base of ulcer covered by slough and/or eschar in wound bed.
-When looking at one: measure the size of wound, depth of wound, presence of
undermining, tunneling, or sinus tract
-Causes: being on bony prominences for too long, thin aging skin, low
consciousness level, altered mobility, malnutrition, bedbound
-Treatments: use 0.9% normal saline solution to irrigate/clean the ulcer (with
carefullness)
-Staging debridement:
Braden Scale-Know what puts patients at risk for pressure injuries based on this
scale - Answer-- shows how much at risk a patient is for a pressure injury.
- Risk factors on the scale include sensory perception, moisture, activity, mobility,
nutrition and friction and shear
Principals of heat and cold application - Answer-Take into account the method in
which you do it, the degree of cold or heat you use, the patient's age, and the
amount of body surface covered by the application
Phases of wound healing including character of drainage - Answer--Hemostasis
(fibrin), Inflammatory phase, Proliferative phase (epithelialization),
remodeling/maturation phase
*Hemostasis: 3-6 days; happens immediately after initial injury exudate forms
causing swelling/pain, increased perfusion->heat/redness
*Inflammatory phase: WBC go into wound where macrophages (they stay there a
while) ingest debris & release growth factors that attract fibroblasts to fill wound
*Proliferation phase: 3-4 days or up to 3 weeks. Wound fills with granulation tissue &
contracts. Capillaries grow across the wound & a thin layer of epithelial cells forms to
resurface the wound.
CLINICAL SKILLS QUESTIONS AND
ANSWERS
Safety risk factors (Patient, Procedure, Equipment and Environmental) - Answer--
Mobility, sensory, cognitive status, impaired mobility, lifestyle choices, lack of safety
awareness
-The home they reside in...is it fully handicapped? Is it lacking quality features of
that?
Nursing process to Assess patient safety risk factors, Diagnoses related to risk
factors, Desired Patient Outcomes, Nursing interventions to promote patient safety
and decrease safety risks. - Answer--Assessment: activity/exercise/medication
history/history of falls/home maintenance & safety
-Diagnosis: risk for falls/impaired home maintenance, risk for injury, deficient
knowledge, risk for poisoning, risk for suffocation, risk for trauma
-Planning: goals/outcomes->prevent & minimize safety threats, are
measurable/realistic, ay include active patient participation, setting priorities,
teamwork/collaboration
-Implementation: health promotion/prevention, individualization or implementation
(Developmental stage, lifestyle, environmental), basic needs, acute care safety
(seizures, poisoning, electrical hazards, radiation, disasters)
-Evaluation: "Are the patients expectations met?", monitor outcomes by the
healthcare team and monitor outcome for each diagnosis while continually assessing
for additional support
Louis Blackman - Answer-lessons learned related to nursing care and patient safety.
Patient factors and other factors that impact wound healing. - Answer--Aging skin,
chronic illness, immobility, malnutrition, fecal/urinary incontinence, altered level of
consciousness, spinal cord/brain injuries, neuromuscular disorders
Skin care and functions of skin - Answer--Functions of skin: protection, body
temperature regulation, psychological, sensation, vitamin D production,
immunological, absorption, elimination
Types of wounds/ wound healing intention - Answer--Intentional/unintentional,
open/closed, acute/chronic, partial thickness, full thickness
-First intention: clean incision with primary closure, minimal scarring, approximated
edges
-Second intention: wound is left open so granulation can occur, large scar results, if
infected left open and later closed when there is no evidence of infection
Expected progression of character (what it looks like) of drainage in healing wound -
Answer-Serosanguinous drainage is the most common type of exudate that is seen
, in wounds. It is thin, pink, and watery in presentation. Purulent drainage is milky,
typically thicker in consistency, and can be gray, green, or yellow in appearance.
Wound healing complications - Answer--Infection, hemorrhage, dehiscence,
evisceration
Care of wounds to include (not limited to) wound irrigation/debridement - Answer--
Irrigation: flush/irrigate the ulcer with 0.9% normal saline solution with carefulness.
Use sterile technique with 35mL syringes and 19-gauge needle to remove any
exudate.
-Debridement: Removing necrotic tissue, aka non-selective removal of nonviable
tissue and debris from the wound-by-wound irrigation, hydrotherapy, or wet-to-dry
dressings
Pressure injuries (everything about them, causes, treatments, staging debridement
etc.) it did not talk about debridement in the PowerPoint but that's basically when u
clean out a stage 4 pressure ulcer, so could u find info on that on her page?? -
Answer--Stages: stage I (nonblanchable erythema of intact skin), stage II (partial
thickness skin loss), stage III (full-thickness skin loss; not involving underlying
fascia), stage IV (full thickness skin loss with extensive destruction bone/tendon
exposed, unstageable (base of ulcer covered by slough and/or eschar in wound bed.
-When looking at one: measure the size of wound, depth of wound, presence of
undermining, tunneling, or sinus tract
-Causes: being on bony prominences for too long, thin aging skin, low
consciousness level, altered mobility, malnutrition, bedbound
-Treatments: use 0.9% normal saline solution to irrigate/clean the ulcer (with
carefullness)
-Staging debridement:
Braden Scale-Know what puts patients at risk for pressure injuries based on this
scale - Answer-- shows how much at risk a patient is for a pressure injury.
- Risk factors on the scale include sensory perception, moisture, activity, mobility,
nutrition and friction and shear
Principals of heat and cold application - Answer-Take into account the method in
which you do it, the degree of cold or heat you use, the patient's age, and the
amount of body surface covered by the application
Phases of wound healing including character of drainage - Answer--Hemostasis
(fibrin), Inflammatory phase, Proliferative phase (epithelialization),
remodeling/maturation phase
*Hemostasis: 3-6 days; happens immediately after initial injury exudate forms
causing swelling/pain, increased perfusion->heat/redness
*Inflammatory phase: WBC go into wound where macrophages (they stay there a
while) ingest debris & release growth factors that attract fibroblasts to fill wound
*Proliferation phase: 3-4 days or up to 3 weeks. Wound fills with granulation tissue &
contracts. Capillaries grow across the wound & a thin layer of epithelial cells forms to
resurface the wound.
