NSG 300 Exam 3 from Grand Canyon University
(GCU) includes accurate and verified questions
covering foundational nursing concepts such as
the nursing process, critical thinking, patient
safety, communication, evidence based practice,
and basic clinical
topic 4 objectives - ....ANSWER ....✔✔ 1. Examine the
factors that place clients at risk for impaired skin
integrity.
2. Apply the elements of a comprehensive wound
assessment.
3. Utilize the planning component of the nursing process
to demonstrate nurse's role and responsibilities for skin
and wound care.
4. Determine nursing interventions that promote healing
and the prevention of wound infections in clients with
impaired skin integrity.
layers of skin - ....ANSWER ....✔✔ epidermis
dermal-epidermal junction
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dermis
subcutaneous layer
pressure injuries pathogenesis - ....ANSWER ....✔✔
pressure intensity (tissue ischemia, blanching), pressure
duration, tissue tolerance
pressure injuries risk factors - ....ANSWER ....✔✔
impaired sensory perception, impaired mobility,
alteration in LOC, shear, friction, moisture
inability to perceive pressure, incontinence/moisture,
decreased activity level, inability to reposition, poor
nutritional intake, friction and shear
stage 1 pressure injury - ....ANSWER ....✔✔ non-
blanchable erythema of intact skin
stage 2 pressure injury - ....ANSWER ....✔✔ partial-
thickness skin loss with exposed dermis
stage 3 pressure injury - ....ANSWER ....✔✔ full-
thickness skin loss
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stage 4 pressure injury - ....ANSWER ....✔✔ full-
thickness skin and tissue loss
unstageable pressure injury - ....ANSWER ....✔✔ full-
thickness skin and tissue loss obscured by slough or
eschar
medical device-related pressure injuries (MDRPI) -
....ANSWER ....✔✔ occurs when the skin or underlying
tissues are subjected to sustained pressure or shear from
medical devices or equipment
medical adhesive-related skin injury (MARSI) -
....ANSWER ....✔✔ occurs from tape and other
medical adhesives
ex: securing ostomy devices
partial-thickness wound repair - ....ANSWER ....✔✔
wounds that involve only a partial loss of skin layers (the
epidermis and superficial dermal layers)
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shallow in depth, moist, and painful, and the wound
base generally appears red
full-thickness wound repair - ....ANSWER ....✔✔
wounds that involve total loss of the skin layers
(epidermis and dermis)
extends into the subcutaneous layer and can be painful,
and the depth and tissue type vary depending on body
location
primary intention healing - ....ANSWER ....✔✔ wound
that is closed
ex: hematoma, surgical incision that is sutured or stapled
healing occurs by epithelialization; heals quickly with
minimal scar formation
secondary intention healing - ....ANSWER ....✔✔
wound edges not closed or approximated
ex: surgical wounds that have tissue loss or
contamination