CPRNE exam prep
Steps for the nursing process? ANS: Assessment
Nursing diagnosis (NANDA)
Planning
Implementation
Evaluation
Serous drainage ANS: clear, watery plasma
sanguineous drainage ANS: Bright red; indicates active bleeding
serosanguineous drainage ANS: mix of plasma and blood (pale red)
Purulent drainage ANS: thick and yellow/green/tan/brown, smells
4 phases of wound healing are and how long do they last? ANS: 1. inflammatory phase -begins within
mins, lasts up to 4 days
2. proliferative phase - 3-24 days, body consolidates its O2, blood, nutrition to figure out how to rebuild
tissues
3. maturation phase - may take place for more than a year
Primary intention healing ANS: flat fine line scar - clean slice
Secondary intention healing ANS: granulation into scar (heals bottom up) gaping
,tertiary intention healing ANS: sutures, staples, tape, combo of primary and secondary intension
decubitus ulcers are caused by? ANS: pressure ulcers or bed sores, caused by pressure on skin again
bony structure
Decubitus ulcer risk factors ANS: altered sensory perception, reduced mobility, moisture, poor nutrition,
friction or shearing.
decubitus ulcer prevention ANS: rotate patients to relieve patients every 2 hours. put a transfer sheet to
prevent friction
define stage 1 pressure ulcers ANS: intact, localized, blanches with pressure
define stage 2 pressure ulcer ANS: partial thickness skin erosion of dermis and epidermis. looks like an
abrasion or open blister with red-pink wound bed
define stage 3 pressure ulcer ANS: full thickness extended into subcutaneous tissue. looks like a greater
and fat may be visible
define stage 4 pressure ulcer ANS: full thickness of all skin layers extending to supporting structures.
may see muscle, tendon and bone. tissue may look black or brown with stringy tissue attached to wound
bed
define unstageable pressure ulcer ANS: necrotic tissue/eschar, unable to see how deep it is
Define eschar ANS: a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite
of a mite, or as a result of anthrax infection.
Pain PQRSTU ANS: P -provocative: does the pain increase w movement?
,Q -quality: what type of pain? stabbing? dull? throbbing?
R -region/radiate: does the pain radiate?
S -severity: on a scale of o to 10
T -time: when did it start?
U -understanding: do you know why you have this pain?
symptoms of pain ANS: increased BP and pulse, increased reps, sweating, dilated pupils, piloerection
(involuntary erection or bristling of hairs). Pt will guard and grimace over painful parts.
infection process, list 4. ANS: 1. colonization
2. Invasion
3. Multiplication
4. spread
infection process:
colonization ANS: Grow pathogens within an individual, Pathogen adhesion (sneeze/cough) no s/s of
infection
infection process:
invasion ANS: Spread to surrounding tissues- may spread through blood (bacteremia)
infection process:
multiplication ANS: Rapid multiplication in nutrient rich body environmentoccurs in cells, macrophages
or blood (sepsis)
infection process:
Spread ANS: Highly invasive bacteria can enters lymph system, blood and internal organs
, stages of infection disease, list 4. ANS: 1. incubation: no symptoms yet
2. prodromal phase: general symptoms
3. invasion period: actually sick
4. Convalescent: getting better
infectious disease: incubation phase ANS: time btwn the entry of the microorganism into the body and
the onset of the symptoms
infectious disease: prodromal phase ANS: time from onset of nonspecific symptoms such as, fatigue,
malaise, low grade temp, generalized muscle aches
infectious disease: invasion phase ANS: • Pathogen is rapidly multiplying & invading further
• Inflammatory & immune system is triggered
• Individual presents with local/ systemic symptoms
• Length of phase depends on the pathogens virulence & host resistance
infectious disease: Convalescent phase ANS: Immune and inflammatory system has successfully
removed the infectious agent
malaise ANS: a vague feeling of physical discomfort or uneasiness
tachycardia ANS: rapid heart rate, usually more than 100 bpm
Bradycardia ANS: abnormally slow heartbeat
bradypnea ANS: slow breathing
Steps for the nursing process? ANS: Assessment
Nursing diagnosis (NANDA)
Planning
Implementation
Evaluation
Serous drainage ANS: clear, watery plasma
sanguineous drainage ANS: Bright red; indicates active bleeding
serosanguineous drainage ANS: mix of plasma and blood (pale red)
Purulent drainage ANS: thick and yellow/green/tan/brown, smells
4 phases of wound healing are and how long do they last? ANS: 1. inflammatory phase -begins within
mins, lasts up to 4 days
2. proliferative phase - 3-24 days, body consolidates its O2, blood, nutrition to figure out how to rebuild
tissues
3. maturation phase - may take place for more than a year
Primary intention healing ANS: flat fine line scar - clean slice
Secondary intention healing ANS: granulation into scar (heals bottom up) gaping
,tertiary intention healing ANS: sutures, staples, tape, combo of primary and secondary intension
decubitus ulcers are caused by? ANS: pressure ulcers or bed sores, caused by pressure on skin again
bony structure
Decubitus ulcer risk factors ANS: altered sensory perception, reduced mobility, moisture, poor nutrition,
friction or shearing.
decubitus ulcer prevention ANS: rotate patients to relieve patients every 2 hours. put a transfer sheet to
prevent friction
define stage 1 pressure ulcers ANS: intact, localized, blanches with pressure
define stage 2 pressure ulcer ANS: partial thickness skin erosion of dermis and epidermis. looks like an
abrasion or open blister with red-pink wound bed
define stage 3 pressure ulcer ANS: full thickness extended into subcutaneous tissue. looks like a greater
and fat may be visible
define stage 4 pressure ulcer ANS: full thickness of all skin layers extending to supporting structures.
may see muscle, tendon and bone. tissue may look black or brown with stringy tissue attached to wound
bed
define unstageable pressure ulcer ANS: necrotic tissue/eschar, unable to see how deep it is
Define eschar ANS: a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite
of a mite, or as a result of anthrax infection.
Pain PQRSTU ANS: P -provocative: does the pain increase w movement?
,Q -quality: what type of pain? stabbing? dull? throbbing?
R -region/radiate: does the pain radiate?
S -severity: on a scale of o to 10
T -time: when did it start?
U -understanding: do you know why you have this pain?
symptoms of pain ANS: increased BP and pulse, increased reps, sweating, dilated pupils, piloerection
(involuntary erection or bristling of hairs). Pt will guard and grimace over painful parts.
infection process, list 4. ANS: 1. colonization
2. Invasion
3. Multiplication
4. spread
infection process:
colonization ANS: Grow pathogens within an individual, Pathogen adhesion (sneeze/cough) no s/s of
infection
infection process:
invasion ANS: Spread to surrounding tissues- may spread through blood (bacteremia)
infection process:
multiplication ANS: Rapid multiplication in nutrient rich body environmentoccurs in cells, macrophages
or blood (sepsis)
infection process:
Spread ANS: Highly invasive bacteria can enters lymph system, blood and internal organs
, stages of infection disease, list 4. ANS: 1. incubation: no symptoms yet
2. prodromal phase: general symptoms
3. invasion period: actually sick
4. Convalescent: getting better
infectious disease: incubation phase ANS: time btwn the entry of the microorganism into the body and
the onset of the symptoms
infectious disease: prodromal phase ANS: time from onset of nonspecific symptoms such as, fatigue,
malaise, low grade temp, generalized muscle aches
infectious disease: invasion phase ANS: • Pathogen is rapidly multiplying & invading further
• Inflammatory & immune system is triggered
• Individual presents with local/ systemic symptoms
• Length of phase depends on the pathogens virulence & host resistance
infectious disease: Convalescent phase ANS: Immune and inflammatory system has successfully
removed the infectious agent
malaise ANS: a vague feeling of physical discomfort or uneasiness
tachycardia ANS: rapid heart rate, usually more than 100 bpm
Bradycardia ANS: abnormally slow heartbeat
bradypnea ANS: slow breathing
