NUR 101 Wounds: NUR 101 Exam: Questions & Answers: Latest Updated Solution

The inflammatory phase of wound healing involves what two processes? (Ans- hemostasis (clotting) and phagocytosis (cleaning of wound) The proliferative phase of wound healing involves what two processes? (Ans- scaffolding of collagen and capillary formation The maturation phase of wound healing involves what two processes? (Ans- wound contracts and scar matures Primary Intention wound healing is characterized by these two traits (Ans- edges of wound are well-approximated, the presence of a thin scar Secondary Intention wound healing is characterized by _____ (Ans- the granulation tissue filling in dead space Tertiary Intention wound healing is characterized by the requirement of _____, _____, or the use of a _____ (Ans- debridement, packing, wound vac Some examples of wound healing complications are _____ (Ans- hemorrhage, hematomas, infection, dehiscence, evisceration, fistula T/F: a decubitus ulcer is the same as a pressure ulcer (Ans- TRUE, other names also include pressure wore, bed sore A nonblanchable erythema of intact skin is considered a Stage _____ Pressure Ulcer (Ans- I A superficial ulcer with loss of epidermis, dermis, or both is considered a Stage _____ Pressure Ulcer (Ans- II An ulcer with skin loss to both the outer and underlying layers of skin tissue with damage all the way down to the fascia is considered a Stage _____ Pressure Ulcer (Ans- III An ulcer with skin loss to both the outer and underlying layers of skin tissue and a great deal of damage and dead tissue in the fascia, muscle, bone, tendon, or joint capsule is considered a Stage _____ Pressure Ulcer (Ans- IV _____ prohibits the staging of pressure ulcers (Ans- Eschar A wound that extends in a horizontal direction immediately beneath the surface of the skin is known as _____ (Ans- undermining T/F: a sinus tract is the same as tunneling in wounds (Ans- TRUE The best way to check for undermining is with a _____ (Ans- sterile cotton swab The most common scale used for assessing the risk for pressure wounds in a client is the _____ scale (Ans- Braden Nurses can perform these interventions in an effort to prevent decubitus ulcers (Ans- ongoing assessments (recognizing early s/s such as localized redness or pallor, tenderness, a burning sensation, coldness, edema), proper positioning (use of support devices on pressure points, turning q2h or as frequently as needed), assuring sheets are not wrinkled (wrinkles can cause friction), utilizing egg crate or flotation mattress (reduces pressure on bony prominences), sheepskin pad (prevents friction), limit HOB elevation to <30 degrees (reduces shearing force), ensuring proper nutrition (Vitamin C, Zinc, protein (healing), plenty of fluids), maintaining meticulous hygiene (keep the skin clean and dry, moisturize dry skin), client/family teaching (instruct on why these interventions are necessary to promote compliance) What factors influence how wound care is provided? (Ans- type of wound, location of wound, size of wound, type and amount of exudate, state of wound (open/closed), integrity of surrounding skin, presence of complicating factors What are some responsibilities of the nurse caring for a client with a wound(s)? (Ans- providing ongoing assessment of the wound(s), keeping the area free from body excretions, changing saturated dressings prn, applying protective ointment/paste prn, using aseptic technique, administering antibiotics as ordered When talking about the RYP system for wounds, what is necessary for each part of the system? (Ans- red wounds-protect, yellow wounds-cleanse, black wounds-debride When cleansing a wound, go from _____ contaminated to _____ contaminated (Ans- least, most When irrigating a wound, allow solution to flow from _____ contaminated to _____ contaminated (Ans- least, most Wound irrigation is the washing or flushing out of an area. It is a special means of cleansing wound of _____ and _____ (Ans- exudate, debris Dressings protect wounds from _____ injury and from _____ (Ans- mechanical, microbial contamination Dressings provide high humidity and _____ to wounds (Ans- thermal insulation Gauze, Telfa Gauze, Petrolatum Gauze, ABDs, Transparent Wound Barriers, Hydrocolloids, Hydrogels (Ans- examples of dressing types Gauze comes in sizes of _____ or _____ (Ans- 2x2, 4x4 Gauze supports debridement if applied and kept _____ (Ans- moist Gauze can be used to maintain a _____ wound surface (Ans- moist Gauze can be used as a filler dressing in _____ (Ans- sinus tracts