NURS 105 FINAL EXAM QUESTIONS AND CORRECT ANSWERS
LATEST VERSION THIS YEAR
List a few elements that cause pressure injuries
(Ans- pressure, friction, shearing, impaired sensory perception, impaired
mobility, increased moisture
Explain blanching
(Ans- occurs when the normal red tones of the light-skinned patient are
present
What are the characteristics of a stage one pressure ulcer?
Pg. 1239 for pictures
(Ans- intact skin with non-blanchable erythema or dyschromia (darkening);
redness
What are the characteristics of a stage two pressure ulcer?
Pg. 1239 for pictures
(Ans- partial-thickness injury with visibility to the papillary layer of the
dermis
What are the characteristics of a stage three pressure ulcer?
Pg. 1239 for pictures
(Ans- destruction of the papillary and reticular layers but not the
subcutaneous tissue
,What are the characteristics of a stage four pressure ulcer?
Pg. 1239 for pictures
(Ans- deep, full-thickness tissue loss with exposed bone, tendon, or
muscle
What are the characteristics of an unstagable pressure ulcer?
Pg. 1239 for pictures
(Ans- full-thickness skin and tissue loss obscured by slough or eschar
List a few ways to prevent pressure ulcers
(Ans- repositioning at least every two hours, use cushions/protectors, use
transfer devices, apply creams, keep bedding and clothing free of
folds/wrinkles, improve nutrient intake
Wound classification: Onset and Duration
(Ans- acute= caused by trauma or surgical incisions; wound edges are
clean and intact; will be restored quickly
chronic= chronic inflammation or repetitive irritation to wound; impeded
healing
Wound classification: Healing Process
, (Ans- Primary intention: closed wound
Secondary intention: wound edges are not approximated (closed)
Tertiary intention: wound is left open for several days then edges are
approximated (closed)
Wound drainage: Describe serous, purulent, serosanguineous, and
sanguineous fluid
(Ans- Serous~ clear light pink/yellow healing fluid
Purulent~ thick yellow, green, tan, or brown fluid; can be odorous
Serosanguineous~ pale, pink, watery fluid
Sanguineous~ bright red fluid; indicative of active bleeding
How can you detect hemorrhaging?
(Ans- by looking for distention or swelling of the affected body part, a
change in the type and amount of drainage from a surgical drain, or signs
and symptoms of hypovolemic shock
Explain the characteristics of different types of tissue: granulation, slough,
eschar
(Ans- Granulation~ red, moist tissue
Slough~ soft yellow or white tissue; stringy substance attached to wound
bed
Eschar~ black, brown, tan, or neurotic tissue
**must be removed for healing to occur
What needs to be documented after assessing a wound?
(Ans-
~type of wound/staging
~dressing type
~blanchable/nonblanchable
LATEST VERSION THIS YEAR
List a few elements that cause pressure injuries
(Ans- pressure, friction, shearing, impaired sensory perception, impaired
mobility, increased moisture
Explain blanching
(Ans- occurs when the normal red tones of the light-skinned patient are
present
What are the characteristics of a stage one pressure ulcer?
Pg. 1239 for pictures
(Ans- intact skin with non-blanchable erythema or dyschromia (darkening);
redness
What are the characteristics of a stage two pressure ulcer?
Pg. 1239 for pictures
(Ans- partial-thickness injury with visibility to the papillary layer of the
dermis
What are the characteristics of a stage three pressure ulcer?
Pg. 1239 for pictures
(Ans- destruction of the papillary and reticular layers but not the
subcutaneous tissue
,What are the characteristics of a stage four pressure ulcer?
Pg. 1239 for pictures
(Ans- deep, full-thickness tissue loss with exposed bone, tendon, or
muscle
What are the characteristics of an unstagable pressure ulcer?
Pg. 1239 for pictures
(Ans- full-thickness skin and tissue loss obscured by slough or eschar
List a few ways to prevent pressure ulcers
(Ans- repositioning at least every two hours, use cushions/protectors, use
transfer devices, apply creams, keep bedding and clothing free of
folds/wrinkles, improve nutrient intake
Wound classification: Onset and Duration
(Ans- acute= caused by trauma or surgical incisions; wound edges are
clean and intact; will be restored quickly
chronic= chronic inflammation or repetitive irritation to wound; impeded
healing
Wound classification: Healing Process
, (Ans- Primary intention: closed wound
Secondary intention: wound edges are not approximated (closed)
Tertiary intention: wound is left open for several days then edges are
approximated (closed)
Wound drainage: Describe serous, purulent, serosanguineous, and
sanguineous fluid
(Ans- Serous~ clear light pink/yellow healing fluid
Purulent~ thick yellow, green, tan, or brown fluid; can be odorous
Serosanguineous~ pale, pink, watery fluid
Sanguineous~ bright red fluid; indicative of active bleeding
How can you detect hemorrhaging?
(Ans- by looking for distention or swelling of the affected body part, a
change in the type and amount of drainage from a surgical drain, or signs
and symptoms of hypovolemic shock
Explain the characteristics of different types of tissue: granulation, slough,
eschar
(Ans- Granulation~ red, moist tissue
Slough~ soft yellow or white tissue; stringy substance attached to wound
bed
Eschar~ black, brown, tan, or neurotic tissue
**must be removed for healing to occur
What needs to be documented after assessing a wound?
(Ans-
~type of wound/staging
~dressing type
~blanchable/nonblanchable
