NURS 6011 STUDY GUIDE FOR EXAM 3
QUESTIONS WITH COMPLETE SOLUTIONS!!
normal BP Answer - 120/80
normal respiratory rate Answer - 12-20
normal pulse rate Answer - 60-100
Normal temperature Answer - 97.8-99.1
debridement Answer - cleaning away devitalized tissue and foreign matter
from a wound
dehiscence Answer - separation of layers of a surgical wound; may be partial,
superficial or a complete disruption of the surgical wound
desiccation Answer - dehydration
the process of being rendered free from moisture
epithelialization Answer - stage of wound healing in which epithelial cells form
across the surface of a wound; tissue color ranges from the color of ground
glass to pink
,eschar Answer - thick, leathery, scar or dry crust that is necrotic and must be
removed for adequate healing to occur
evisceration Answer - protrusion of viscera through an incision
purulent drainage Answer - compromised of WBCs, liquefied dead tissue
debris, and both dead and live bacteria
an intentional wound is the result of? Answer - planned invasive therapy or
treatment
examples are wound resulting from surgery, IV therapy, and lumbar puncture
in older adults what are age related changes that occur that could affect wound
healing Answer - skin loses turgor and is more fragile
decreased secretion of enzymes and absorption of nutrients and minerals may
increase risk for delayed wound healing
risk of infection increases because:
-slower inflammatory response
-reduced antibody production and endocrine system function
-increased incidence of chronic illnesses, such as diabetes and CV disease, that
compromise circulation and tissue oxygenation
You have a 6th grader who has been getting bad grades lately, rubs their eyes
frequently, visual acuity is poor what is the nursing diagnosis? Answer -
ineffective role performance related to visual impairment
, in an older adult the skin loses turgor and is more fragile what are some
nursing interventions to help with that? Answer - maintain hydration and IV
fluids as prescribed
maintain record of intake and output
use caution when removing tape
in older adults they experience decreased secretion of enzymes and absorption
of nutrients that increase their risk for delayed wound healing what are some
nursing interventions to combat this? Answer - maintain intake of adequate
calories
ensure that the diet is high in protein, vitamin A, vitamin C and trace elements
monitor lab results such as serum albumin, total protein
in older adults if they have a wound the risk for infections increases what are
some nursing interventions to combat this? Answer - -hand hygiene
-take and record vital signs noting and reporting increased temp
-monitor wound for signs of infection
-administer meds as prescribed
symptoms of infection of a wound include? Answer - purulent drainage
increased drainage
QUESTIONS WITH COMPLETE SOLUTIONS!!
normal BP Answer - 120/80
normal respiratory rate Answer - 12-20
normal pulse rate Answer - 60-100
Normal temperature Answer - 97.8-99.1
debridement Answer - cleaning away devitalized tissue and foreign matter
from a wound
dehiscence Answer - separation of layers of a surgical wound; may be partial,
superficial or a complete disruption of the surgical wound
desiccation Answer - dehydration
the process of being rendered free from moisture
epithelialization Answer - stage of wound healing in which epithelial cells form
across the surface of a wound; tissue color ranges from the color of ground
glass to pink
,eschar Answer - thick, leathery, scar or dry crust that is necrotic and must be
removed for adequate healing to occur
evisceration Answer - protrusion of viscera through an incision
purulent drainage Answer - compromised of WBCs, liquefied dead tissue
debris, and both dead and live bacteria
an intentional wound is the result of? Answer - planned invasive therapy or
treatment
examples are wound resulting from surgery, IV therapy, and lumbar puncture
in older adults what are age related changes that occur that could affect wound
healing Answer - skin loses turgor and is more fragile
decreased secretion of enzymes and absorption of nutrients and minerals may
increase risk for delayed wound healing
risk of infection increases because:
-slower inflammatory response
-reduced antibody production and endocrine system function
-increased incidence of chronic illnesses, such as diabetes and CV disease, that
compromise circulation and tissue oxygenation
You have a 6th grader who has been getting bad grades lately, rubs their eyes
frequently, visual acuity is poor what is the nursing diagnosis? Answer -
ineffective role performance related to visual impairment
, in an older adult the skin loses turgor and is more fragile what are some
nursing interventions to help with that? Answer - maintain hydration and IV
fluids as prescribed
maintain record of intake and output
use caution when removing tape
in older adults they experience decreased secretion of enzymes and absorption
of nutrients that increase their risk for delayed wound healing what are some
nursing interventions to combat this? Answer - maintain intake of adequate
calories
ensure that the diet is high in protein, vitamin A, vitamin C and trace elements
monitor lab results such as serum albumin, total protein
in older adults if they have a wound the risk for infections increases what are
some nursing interventions to combat this? Answer - -hand hygiene
-take and record vital signs noting and reporting increased temp
-monitor wound for signs of infection
-administer meds as prescribed
symptoms of infection of a wound include? Answer - purulent drainage
increased drainage
