NSG300 Exam 2, NSG 300 nursing exam, nursing
questions and answers, clinical nursing exam,
intermediate nursing concepts, NSG300 test prep
what places patients at risk for pressure ulcers/impaired skin
integrity - ans -pressure intensity, pressure duration, tissue
tolerance, impaired sensory perception, impaired mobility,
alteration in LOC, shear, friction, moisture
layers of the skin - ans -epidermis, dermis (collagen)
body's defenses against infection - ans -normal flora,
inflammatory response, immune response
comprehensive wound assessment - ans --ongoing assessment
from time of injury, wound care, any condition changes, and on
scheduled basis
-Important to include cause of injury, history of wound,
treatment, description, response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - ans -assesses risk for developing pressure ulcers;
includes patient's sensory perception, moisture, activity, mobility,
nutrition, friction and shear; the lower the number the higher the
risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
,type 1 ulcers - ans -skin is intact but may be red or pink and warm
to the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may
vary
type 2 ulcers - ans -partial-thickness loss of dermis; shallow
broken skin; red-pink wound bed
type 3 ulcers - ans -full-thickness tissue loss with visible fat
(subcutaneous layer); pale-yellow color; may include slough but
does not obstruct view of depth of injury
type 4 ulcers - ans -full-thickness tissue loss with exposed bone,
muscle, or tendon. possible tunneling and undermining
unstageable pressure ulcer - ans -base of ulcer covered by slough
and/or eschar in the wound bed so the depth is unknown;
exudate;
deep tissue injury - ans -Purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear.
how should you clean a wound - ans -from least to most
contaminated
eschar - ans -black, brown or necrotic tissue in wound bed; needs
to be removed before healing
slough - ans -stringy pale-yellowish tissue that lays in the wound
bed; needs to be removed before healing
,if a patient has slough, eschar, and infectious exudate which one
would you be most concerned about - ans -infectious exudate
factors influencing heat and cold tolerance - ans -Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - ans -location, staging
(depth), type and % of tissue in wound bed, wound dimensions
(including tunneling), exudate description (if odor is present), and
condition of surrounding skin
why is depth of an ulcer important - ans -because the wound
heals inside-out
granulation tissue - ans -good, fresh tissue that forms during the
healing of a wound (wound bed will be red, moist, and shiny)
How does a partial thickness wound heal? - ans -by regeneration
(scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate
serous exudate. 1st 24hrs after wounding.
-epithelial proliferation (reproduction): starts at wound edges and
epidermal cells lining appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist
environment. in dry wound, the cells move down into a moist
level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal
thickness and appear as dry, pink tissue
, How does a full thickness wound heal? - ans -by forming new
tissue/scar formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop
bleeding
-inflammation: damaged tissue and mast cells secrete histamine
(vasodilation of surrounding capillaries and movement of serum
and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation
tissue), the area is filled with replacement tissue (collagen,
contraction, and granulation tissue), and the surface is repaired
(epithelialization)
-maturation: The collagen scar continues to reorganize and gain
strength for several months. Collagen fibers undergo remodeling
or reorganization before assuming their normal appearance
primary intention - ans -wound that is closed/approximated; little
tissue loss; low risk of infection; quick healing with no scar usually
(surgical incision)
secondary intention - ans -a wound with loss of tissue; wound is
not approximated; have to heal from the inside-out; if scarring is
severe, loss of tissue function may be permanent (pressure ulcers,
surgical wound that has tissue loss)
tertiary intention - ans -Wound that is left open for several days,
then wound edges are approximated; doctor can monitor status
of wound
complications of wound healing - ans -hemorrhage, infection,
dehiscence, evisceration
questions and answers, clinical nursing exam,
intermediate nursing concepts, NSG300 test prep
what places patients at risk for pressure ulcers/impaired skin
integrity - ans -pressure intensity, pressure duration, tissue
tolerance, impaired sensory perception, impaired mobility,
alteration in LOC, shear, friction, moisture
layers of the skin - ans -epidermis, dermis (collagen)
body's defenses against infection - ans -normal flora,
inflammatory response, immune response
comprehensive wound assessment - ans --ongoing assessment
from time of injury, wound care, any condition changes, and on
scheduled basis
-Important to include cause of injury, history of wound,
treatment, description, response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - ans -assesses risk for developing pressure ulcers;
includes patient's sensory perception, moisture, activity, mobility,
nutrition, friction and shear; the lower the number the higher the
risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
,type 1 ulcers - ans -skin is intact but may be red or pink and warm
to the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may
vary
type 2 ulcers - ans -partial-thickness loss of dermis; shallow
broken skin; red-pink wound bed
type 3 ulcers - ans -full-thickness tissue loss with visible fat
(subcutaneous layer); pale-yellow color; may include slough but
does not obstruct view of depth of injury
type 4 ulcers - ans -full-thickness tissue loss with exposed bone,
muscle, or tendon. possible tunneling and undermining
unstageable pressure ulcer - ans -base of ulcer covered by slough
and/or eschar in the wound bed so the depth is unknown;
exudate;
deep tissue injury - ans -Purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear.
how should you clean a wound - ans -from least to most
contaminated
eschar - ans -black, brown or necrotic tissue in wound bed; needs
to be removed before healing
slough - ans -stringy pale-yellowish tissue that lays in the wound
bed; needs to be removed before healing
,if a patient has slough, eschar, and infectious exudate which one
would you be most concerned about - ans -infectious exudate
factors influencing heat and cold tolerance - ans -Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - ans -location, staging
(depth), type and % of tissue in wound bed, wound dimensions
(including tunneling), exudate description (if odor is present), and
condition of surrounding skin
why is depth of an ulcer important - ans -because the wound
heals inside-out
granulation tissue - ans -good, fresh tissue that forms during the
healing of a wound (wound bed will be red, moist, and shiny)
How does a partial thickness wound heal? - ans -by regeneration
(scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate
serous exudate. 1st 24hrs after wounding.
-epithelial proliferation (reproduction): starts at wound edges and
epidermal cells lining appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist
environment. in dry wound, the cells move down into a moist
level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal
thickness and appear as dry, pink tissue
, How does a full thickness wound heal? - ans -by forming new
tissue/scar formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop
bleeding
-inflammation: damaged tissue and mast cells secrete histamine
(vasodilation of surrounding capillaries and movement of serum
and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation
tissue), the area is filled with replacement tissue (collagen,
contraction, and granulation tissue), and the surface is repaired
(epithelialization)
-maturation: The collagen scar continues to reorganize and gain
strength for several months. Collagen fibers undergo remodeling
or reorganization before assuming their normal appearance
primary intention - ans -wound that is closed/approximated; little
tissue loss; low risk of infection; quick healing with no scar usually
(surgical incision)
secondary intention - ans -a wound with loss of tissue; wound is
not approximated; have to heal from the inside-out; if scarring is
severe, loss of tissue function may be permanent (pressure ulcers,
surgical wound that has tissue loss)
tertiary intention - ans -Wound that is left open for several days,
then wound edges are approximated; doctor can monitor status
of wound
complications of wound healing - ans -hemorrhage, infection,
dehiscence, evisceration
