Exam 3 nur 155 Questions And
Correct Answers
Laceration Answers Tissue torn apart often by accidents
Abrasion Answers Surface scrape either unintentional or intentional
Contusion Answers Blow from a blunt instrument
Avulsion Answers A wound that occurs when tissue is separated from the
body
Penetrating wound Answers Penetration of the skin and underlying tissue
Skin tear Answers a break or rip in the outer layers of the skin; the
epidermis separates from the underlying tissues
Labs associated with wounds Answers WBC >
hEMOGLOBIN < (O2 TO TISSUE)
SERUM PROTEIN (CONTAIN ALBUMIN)
WOUND CULTURE: PT, PTT, INR, PLATELET.
Normal lab value Answers WBC 5-10
hemoglobin: male 14-18, female 12-16
Albumin: 3.5-5
PTT: 20-30 SEC
PT: 11-12.5 SEC
INR: 0.9-1.2 SEC
PLT: 150-400
, STATE THE FOUR STAGES OF PRESSURE ULCER Answers Stage 1:
nonblanchable errythema, no ulceration
stage 2: partial thickness, skin loss abrasion involving epidermis and dermis
stage 3: full thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to but not through underline
fascia
stage 4: full thickness skin loss with tissue necrosis with damage to muscle
and bone
Braden scale Answers A tool for predicting pressure ulcer risk
total 23 points, < 18 at risk
Norton pressure area risk assesment Answers Total score 24, 15-16
considered indicators not predictors at risk
RYB- RED Answers regeneration phase- gentle cleansing don't apply
pressure protect agranulation tissue
use non-cytotoxic wound cleanser w/o pressure
alcohol free barrier film
PROTECT-COVER
RYB- BLACK Answers DEBRIDE (REMOVAL OF NECROTIC MATERIAL)
RYB- YELLOW Answers CLEANSE
Sharp debridement Answers requires use of scalpel, scissors, and/or
forceps to selectively remove devitalized tissues, foreign materials or debris
from a wound.
Mechanical debridement Answers scrubbing force or damp to damp
dressings
Chemical debridement Answers collagenase enzymes
Transparent film Answers film dressings are thin membranes made from
transparent polyurethane with water resistant adhesives. allow easy visual
inspection of the wound since they are transparent. STAGE 1
impregnated nonadherent Answers Woven and non woven synthetic
materials that are impregnated with petroleum, saline, zinc.
Correct Answers
Laceration Answers Tissue torn apart often by accidents
Abrasion Answers Surface scrape either unintentional or intentional
Contusion Answers Blow from a blunt instrument
Avulsion Answers A wound that occurs when tissue is separated from the
body
Penetrating wound Answers Penetration of the skin and underlying tissue
Skin tear Answers a break or rip in the outer layers of the skin; the
epidermis separates from the underlying tissues
Labs associated with wounds Answers WBC >
hEMOGLOBIN < (O2 TO TISSUE)
SERUM PROTEIN (CONTAIN ALBUMIN)
WOUND CULTURE: PT, PTT, INR, PLATELET.
Normal lab value Answers WBC 5-10
hemoglobin: male 14-18, female 12-16
Albumin: 3.5-5
PTT: 20-30 SEC
PT: 11-12.5 SEC
INR: 0.9-1.2 SEC
PLT: 150-400
, STATE THE FOUR STAGES OF PRESSURE ULCER Answers Stage 1:
nonblanchable errythema, no ulceration
stage 2: partial thickness, skin loss abrasion involving epidermis and dermis
stage 3: full thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to but not through underline
fascia
stage 4: full thickness skin loss with tissue necrosis with damage to muscle
and bone
Braden scale Answers A tool for predicting pressure ulcer risk
total 23 points, < 18 at risk
Norton pressure area risk assesment Answers Total score 24, 15-16
considered indicators not predictors at risk
RYB- RED Answers regeneration phase- gentle cleansing don't apply
pressure protect agranulation tissue
use non-cytotoxic wound cleanser w/o pressure
alcohol free barrier film
PROTECT-COVER
RYB- BLACK Answers DEBRIDE (REMOVAL OF NECROTIC MATERIAL)
RYB- YELLOW Answers CLEANSE
Sharp debridement Answers requires use of scalpel, scissors, and/or
forceps to selectively remove devitalized tissues, foreign materials or debris
from a wound.
Mechanical debridement Answers scrubbing force or damp to damp
dressings
Chemical debridement Answers collagenase enzymes
Transparent film Answers film dressings are thin membranes made from
transparent polyurethane with water resistant adhesives. allow easy visual
inspection of the wound since they are transparent. STAGE 1
impregnated nonadherent Answers Woven and non woven synthetic
materials that are impregnated with petroleum, saline, zinc.
