PPNC Exam 1 ACTUAL Exam Questions
and CORRECT Answers
Nursing Process Steps - CORRECT ANSWER - ADPIE
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Nursing Process Step 3: Planning - CORRECT ANSWER - -Identify priorities
-generate solutions and outcomes to reduce risks of injury
- SMART outcomes
-develop PLAN OF CARE (POC): assessment/teaching, concealing, must be individualized to
patient
-communicate/document plan
S.M.A.R.T. - CORRECT ANSWER - Specific,
Measurable,
Attainable,
Realistic,
Timely
Mobility - CORRECT ANSWER - a person's ability to move about freely
Bed Rest - CORRECT ANSWER - - intervention that restricts patients to bed for
therapeutic reasons and is sometimes prescribed.
-decreasing the oxygen needs of the body, reducing cardiac workload and pain, and allowing a
patient who is debilitated to rest.
,Shear Force - CORRECT ANSWER - the sliding movement of skin and subcutaneous
tissue while the underlying muscle and bone are stationary
Friction - CORRECT ANSWER - - the force of 2 surfaces moving across eachother.
- affects the top layer of epidermis NOT the deeper tissue
Risk Factors for pressure ulcer development - CORRECT ANSWER - - impaired sensory
perception
- impaired/decreased mobility
- altered LOC (cant think to reposition
- shearing
- friction
- moisture/incontinence
- spinal injury/hipfracture
Stage 1 Pressure Injury Definition - CORRECT ANSWER - Non-blanchable erythema of
intact skin
Stage 1 Pressure Injury Picture - CORRECT ANSWER - see picture
Stage 2 Pressure Injury Definition - CORRECT ANSWER - Partial-Thickness skin loss
with exposed dermis
Stage 2 Pressure Injury Picture - CORRECT ANSWER - see picture
Stage 3 Pressure Injury Definition - CORRECT ANSWER - Full-Thickness skin loss
Stage 3 Pressure Injury Picture - CORRECT ANSWER - see picture
, Stage 4 Pressure Injury Definition - CORRECT ANSWER - Full thickness skin and tissue
loss
Stage 4 Pressure Injury Picture - CORRECT ANSWER - see picture
Deep Pressure Injury Definition - CORRECT ANSWER - -skin intact
-purple
-unstageable
Deep Pressure Injury Picture - CORRECT ANSWER - see picture
Unstageable 1 Pressure Injury Definition - CORRECT ANSWER - Eschar = black
necrotic tissue
Slough = stringy slimy debris of dead skin cells
Unstageable 1 Pressure Injury Picture - CORRECT ANSWER - see picture
Exudate definition - CORRECT ANSWER - -wound drainage
Serous Exudate - CORRECT ANSWER - clear, watery plasma
Purulent Exudate - CORRECT ANSWER - thick, yellow-green, contains leukocytes, cell
debris, and microorganisms
Serosanguineous Exudate - CORRECT ANSWER - Pale, pink, watery; mixture of clear
and red fluid
and CORRECT Answers
Nursing Process Steps - CORRECT ANSWER - ADPIE
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Nursing Process Step 3: Planning - CORRECT ANSWER - -Identify priorities
-generate solutions and outcomes to reduce risks of injury
- SMART outcomes
-develop PLAN OF CARE (POC): assessment/teaching, concealing, must be individualized to
patient
-communicate/document plan
S.M.A.R.T. - CORRECT ANSWER - Specific,
Measurable,
Attainable,
Realistic,
Timely
Mobility - CORRECT ANSWER - a person's ability to move about freely
Bed Rest - CORRECT ANSWER - - intervention that restricts patients to bed for
therapeutic reasons and is sometimes prescribed.
-decreasing the oxygen needs of the body, reducing cardiac workload and pain, and allowing a
patient who is debilitated to rest.
,Shear Force - CORRECT ANSWER - the sliding movement of skin and subcutaneous
tissue while the underlying muscle and bone are stationary
Friction - CORRECT ANSWER - - the force of 2 surfaces moving across eachother.
- affects the top layer of epidermis NOT the deeper tissue
Risk Factors for pressure ulcer development - CORRECT ANSWER - - impaired sensory
perception
- impaired/decreased mobility
- altered LOC (cant think to reposition
- shearing
- friction
- moisture/incontinence
- spinal injury/hipfracture
Stage 1 Pressure Injury Definition - CORRECT ANSWER - Non-blanchable erythema of
intact skin
Stage 1 Pressure Injury Picture - CORRECT ANSWER - see picture
Stage 2 Pressure Injury Definition - CORRECT ANSWER - Partial-Thickness skin loss
with exposed dermis
Stage 2 Pressure Injury Picture - CORRECT ANSWER - see picture
Stage 3 Pressure Injury Definition - CORRECT ANSWER - Full-Thickness skin loss
Stage 3 Pressure Injury Picture - CORRECT ANSWER - see picture
, Stage 4 Pressure Injury Definition - CORRECT ANSWER - Full thickness skin and tissue
loss
Stage 4 Pressure Injury Picture - CORRECT ANSWER - see picture
Deep Pressure Injury Definition - CORRECT ANSWER - -skin intact
-purple
-unstageable
Deep Pressure Injury Picture - CORRECT ANSWER - see picture
Unstageable 1 Pressure Injury Definition - CORRECT ANSWER - Eschar = black
necrotic tissue
Slough = stringy slimy debris of dead skin cells
Unstageable 1 Pressure Injury Picture - CORRECT ANSWER - see picture
Exudate definition - CORRECT ANSWER - -wound drainage
Serous Exudate - CORRECT ANSWER - clear, watery plasma
Purulent Exudate - CORRECT ANSWER - thick, yellow-green, contains leukocytes, cell
debris, and microorganisms
Serosanguineous Exudate - CORRECT ANSWER - Pale, pink, watery; mixture of clear
and red fluid
