NSG 300 Exam V2
1. secondary intention: 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)
2. tertiary intention: Wound that is left open for several days, then wound edgesare
approximated; doctor can monitor status of wound
3. complications of wound healing: hemorrhage, infection, dehiscence, eviscer-ation
4. CMS: created policy for hospitals to no longer receive additional reimbursementfor care
related to eight conditions to improve quality of health care
5. signs and symptoms of wound infection: Contaminated or traumatic wounds:2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound siteElevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)Dehiscence
Evisceration
6. what is needed for wound healing: protein (albumin)
7. factors influencing pressure ulcer formation and wound healing: -nutrition
-tissue perfusion
-infection
-age
-psychosocial impacts (body image)
8. when should you give an analgesic: at least 30 minutes before removing awound dressing
9. Scientific Method nursing: •identify the problem,
• collect data,
• formulate a question or hypothesis,
•test the question or hypothesis, andevaluate results of the test or study.
10. With drainage, what should you assess: amount, color, odor, and consistency(if drainage is
pungent or strong, suspect infection)
11. The use of diagnostic reasoning involves a rigorous approach to clinical practice and
demonstrates that critical thinking cannot be done : -haphazardly
12. Jackson-Pratt drain: hollow bulb-like device used to collect drainage; needs gentle-
negative suction (squeeze before you tighten the cap)
,13. what is the purpose of the nursing process: to dx and tx human responses to actual or
potential health problems.
14. nursing interventions for the prevention of pressure ulcers: -skin care and management of
incontinence
-mechanical loading and support devices
-education
-reposition pt every 2 hrs
-apply barrier cream
15. what do the WOCN guidelines recommend: a 30 degree lateral position toprevent
positioning over bony prominences
16. wound management: Debridement: mechanical, autolytic, chemical,sharp/surgical
Education Nutritional statusProtein status Hemoglobin
17. debridement: removal of foreign material and dead or damaged tissue from awound
18. autolytic debridement: uses synthetic dressings over a wound to allow the eschar to be
self-digested by the action of enzymes that are present in wound fluids.
19. chemical debridement: may use topical enzymes to induce changes in thesubstrate
resulting in the breakdown of necrotic tissue. (Dakin's solution)
20. surgical debridement: Removal of devitalized tissue by using a scalpel, scis-sors, or other
sharp instrument
21. when is nutritional assessment recommended? By who?: within 24 hoursof admission by
TJC
22. what places patients at risk for pressure ulcers/impaired skin integrity: - pressure
intensity, pressure duration, tissue tolerance, impaired sensory perception,impaired mobility,
alteration in LOC, shear, friction, moisture
23. layers of the skin: epidermis, dermis (collagen)
24. body's defenses against infection: normal flora, inflammatory response, im-mune
response
25. comprehensive wound assessment: -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
26. Braden Scale: assesses risk for developing pressure ulcers; includes patient's sensory
perception, moisture, activity, mobility, nutrition, friction and shear; the lowerthe number the
, higher the risk
>9= very high risk10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
27. type 1 ulcers: skin is intact but may be red or pink and warm to the touch; noblanching
-for POC, there may be no noticeable blanching but skin color may vary
28. type 2 ulcers: partial-thickness loss of dermis; shallow broken skin; red-pinkwound bed
29. type 3 ulcers: full-thickness tissue loss with visible fat (subcutaneous layer); pale-yellow
color; may include slough but does not obstruct view of depth of injury
30. type 4 ulcers: full-thickness tissue loss with exposed bone, muscle, or tendon.possible
tunneling and undermining
31. unstageable pressure ulcer: base of ulcer covered by slough and/or eschar inthe wound bed
so the depth is unknown; exudate;
32. deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-
filled blister due to damage of underlying soft tissue from pressure and/orshear.
33. how should you clean a wound: from least to most contaminated
34. eschar: black, brown or necrotic tissue in wound bed; needs to be removedbefore healing
35. slough: stringy pale-yellowish tissue that lays in the wound bed; needs to beremoved
before healing
36. if a patient has slough, eschar, and infectious exudate which one wouldyou be most
concerned about: infectious exudate
37. factors influencing heat and cold tolerance: Exposure timeExposed skin
TemperatureAge
Perception of sensory stimuli
38. assessment for pressure ulcers includes: location, staging (depth), type and
% of tissue in wound bed, wound dimensions (including tunneling), exudate descrip-tion (if odor
is present), and condition of surrounding skin
39. why is depth of an ulcer important: because the wound heals inside-out
40. granulation tissue: good, fresh tissue that forms during the healing of a wound(wound bed
will be red, moist, and shiny)
41. How does a partial thickness wound heal?: by regeneration (scratch or abra-sion)
1. secondary intention: 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)
2. tertiary intention: Wound that is left open for several days, then wound edgesare
approximated; doctor can monitor status of wound
3. complications of wound healing: hemorrhage, infection, dehiscence, eviscer-ation
4. CMS: created policy for hospitals to no longer receive additional reimbursementfor care
related to eight conditions to improve quality of health care
5. signs and symptoms of wound infection: Contaminated or traumatic wounds:2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound siteElevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)Dehiscence
Evisceration
6. what is needed for wound healing: protein (albumin)
7. factors influencing pressure ulcer formation and wound healing: -nutrition
-tissue perfusion
-infection
-age
-psychosocial impacts (body image)
8. when should you give an analgesic: at least 30 minutes before removing awound dressing
9. Scientific Method nursing: •identify the problem,
• collect data,
• formulate a question or hypothesis,
•test the question or hypothesis, andevaluate results of the test or study.
10. With drainage, what should you assess: amount, color, odor, and consistency(if drainage is
pungent or strong, suspect infection)
11. The use of diagnostic reasoning involves a rigorous approach to clinical practice and
demonstrates that critical thinking cannot be done : -haphazardly
12. Jackson-Pratt drain: hollow bulb-like device used to collect drainage; needs gentle-
negative suction (squeeze before you tighten the cap)
,13. what is the purpose of the nursing process: to dx and tx human responses to actual or
potential health problems.
14. nursing interventions for the prevention of pressure ulcers: -skin care and management of
incontinence
-mechanical loading and support devices
-education
-reposition pt every 2 hrs
-apply barrier cream
15. what do the WOCN guidelines recommend: a 30 degree lateral position toprevent
positioning over bony prominences
16. wound management: Debridement: mechanical, autolytic, chemical,sharp/surgical
Education Nutritional statusProtein status Hemoglobin
17. debridement: removal of foreign material and dead or damaged tissue from awound
18. autolytic debridement: uses synthetic dressings over a wound to allow the eschar to be
self-digested by the action of enzymes that are present in wound fluids.
19. chemical debridement: may use topical enzymes to induce changes in thesubstrate
resulting in the breakdown of necrotic tissue. (Dakin's solution)
20. surgical debridement: Removal of devitalized tissue by using a scalpel, scis-sors, or other
sharp instrument
21. when is nutritional assessment recommended? By who?: within 24 hoursof admission by
TJC
22. what places patients at risk for pressure ulcers/impaired skin integrity: - pressure
intensity, pressure duration, tissue tolerance, impaired sensory perception,impaired mobility,
alteration in LOC, shear, friction, moisture
23. layers of the skin: epidermis, dermis (collagen)
24. body's defenses against infection: normal flora, inflammatory response, im-mune
response
25. comprehensive wound assessment: -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
26. Braden Scale: assesses risk for developing pressure ulcers; includes patient's sensory
perception, moisture, activity, mobility, nutrition, friction and shear; the lowerthe number the
, higher the risk
>9= very high risk10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
27. type 1 ulcers: skin is intact but may be red or pink and warm to the touch; noblanching
-for POC, there may be no noticeable blanching but skin color may vary
28. type 2 ulcers: partial-thickness loss of dermis; shallow broken skin; red-pinkwound bed
29. type 3 ulcers: full-thickness tissue loss with visible fat (subcutaneous layer); pale-yellow
color; may include slough but does not obstruct view of depth of injury
30. type 4 ulcers: full-thickness tissue loss with exposed bone, muscle, or tendon.possible
tunneling and undermining
31. unstageable pressure ulcer: base of ulcer covered by slough and/or eschar inthe wound bed
so the depth is unknown; exudate;
32. deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-
filled blister due to damage of underlying soft tissue from pressure and/orshear.
33. how should you clean a wound: from least to most contaminated
34. eschar: black, brown or necrotic tissue in wound bed; needs to be removedbefore healing
35. slough: stringy pale-yellowish tissue that lays in the wound bed; needs to beremoved
before healing
36. if a patient has slough, eschar, and infectious exudate which one wouldyou be most
concerned about: infectious exudate
37. factors influencing heat and cold tolerance: Exposure timeExposed skin
TemperatureAge
Perception of sensory stimuli
38. assessment for pressure ulcers includes: location, staging (depth), type and
% of tissue in wound bed, wound dimensions (including tunneling), exudate descrip-tion (if odor
is present), and condition of surrounding skin
39. why is depth of an ulcer important: because the wound heals inside-out
40. granulation tissue: good, fresh tissue that forms during the healing of a wound(wound bed
will be red, moist, and shiny)
41. How does a partial thickness wound heal?: by regeneration (scratch or abra-sion)
