NSE 211 Final Exam – Study Guide &
Practice Questions
wound - -- answer --break in the continuity of body structure, caused by violence,
trauma, or surgery to tissue bodies
stage 3 PI - -- answer --- full thickness tissue loss of skin, where *adipose,
granulation tissue & epibole are often present*
- slough, eschar or both may be visible.
- undermining & tunneling may occur.
- *fascia, muscle tendon, ligament, cartilage & bone aren't exposed*.
stage 4 PI - -- answer --- full thickness skin & tissue loss
- *exposed fascia, muscle tendon, ligament, cartilage or bone in the ulcer*.
- slough, eschar or both may be seen.
unstageable PI - -- answer --- full thickness skin & tissue loss in where *tissue
damage within ulcer can't be confirmed* b/c its blocked by slough or eschar.
- if slough/eschar is removed, stage 3 or 4 PI would be seen. Stable eschar should
not be removed however.
,undermining - -- answer --open area, or tunneling under edge of a wound
Bates Jenson Wound Assessment Tool (BWAT) looks at ... - -- answer --- location
- size
- depth
- edges
- undermining
- necrotic tissue type & amount
- exudate type & amount
- periwound
- peripheral tissue edema
- peripheral tissue induration
- granulation tissue
- epithelialization
what things do you document about a PI? - -- answer --- size
- evidence of healing
- characteristics of drainage
- client teaching & pain
how do you evaluate wound healing? - -- answer --- is wound healing or
becoming chronic?
- what's the dressing effectiveness (adherence, comfort, moisture control)
,- psychosocial impact on body image, sexuality, & self concept (smells, scars,
exudates, temp or permanent prosthetics)
What does braden scare evaluate? - -- answer --- sensory perception
- moisture
- activity lvls
- mobility
- nutrition
- friction & shear
What are the 10 Rights of Medication Administration - -- answer --1) right
medication
2) right dose
3) right patient
4) right route
5) right time & frequency
6) right documentation
7) right reason
8) right to refuse
9) right patient education
10) right evaluation
calculation formula - -- answer --DO/DH x AH = x
, what is the benefit of IM medications? - -- answer --provides faster medication
absorption than the SC route b/c the muscle area has *greater vascularity* > SC &
ID
do not touch which parts of syringe? - -- answer --tip, and plunger
3 parts of a needle - -- answer --hub, shaft, bevel
what size needle for IM injections? - -- answer --2.5-3.8 cm
what size needle for SC injections? - -- answer --1-1.6 cm
blunt fill needle is used for - -- answer --vial withdrawal
blunt filter needle is used for - -- answer --ampoule withdrawal for IV bags & luer-
activated valves
how to perform the one hand scoop technique - -- answer --1) place cap on flat
surface, and remove hand from cap
2) w/ one hand, hold syringe & use needle to "scoop up" the cap
3) when cap covers needle completely, use other hand to secure cap from the
bottom.
ampules - -- answer --contain single doses of medication in a liquid. made up of
glass w/ a constricted neck that *must be snapped off to access the medication*
Practice Questions
wound - -- answer --break in the continuity of body structure, caused by violence,
trauma, or surgery to tissue bodies
stage 3 PI - -- answer --- full thickness tissue loss of skin, where *adipose,
granulation tissue & epibole are often present*
- slough, eschar or both may be visible.
- undermining & tunneling may occur.
- *fascia, muscle tendon, ligament, cartilage & bone aren't exposed*.
stage 4 PI - -- answer --- full thickness skin & tissue loss
- *exposed fascia, muscle tendon, ligament, cartilage or bone in the ulcer*.
- slough, eschar or both may be seen.
unstageable PI - -- answer --- full thickness skin & tissue loss in where *tissue
damage within ulcer can't be confirmed* b/c its blocked by slough or eschar.
- if slough/eschar is removed, stage 3 or 4 PI would be seen. Stable eschar should
not be removed however.
,undermining - -- answer --open area, or tunneling under edge of a wound
Bates Jenson Wound Assessment Tool (BWAT) looks at ... - -- answer --- location
- size
- depth
- edges
- undermining
- necrotic tissue type & amount
- exudate type & amount
- periwound
- peripheral tissue edema
- peripheral tissue induration
- granulation tissue
- epithelialization
what things do you document about a PI? - -- answer --- size
- evidence of healing
- characteristics of drainage
- client teaching & pain
how do you evaluate wound healing? - -- answer --- is wound healing or
becoming chronic?
- what's the dressing effectiveness (adherence, comfort, moisture control)
,- psychosocial impact on body image, sexuality, & self concept (smells, scars,
exudates, temp or permanent prosthetics)
What does braden scare evaluate? - -- answer --- sensory perception
- moisture
- activity lvls
- mobility
- nutrition
- friction & shear
What are the 10 Rights of Medication Administration - -- answer --1) right
medication
2) right dose
3) right patient
4) right route
5) right time & frequency
6) right documentation
7) right reason
8) right to refuse
9) right patient education
10) right evaluation
calculation formula - -- answer --DO/DH x AH = x
, what is the benefit of IM medications? - -- answer --provides faster medication
absorption than the SC route b/c the muscle area has *greater vascularity* > SC &
ID
do not touch which parts of syringe? - -- answer --tip, and plunger
3 parts of a needle - -- answer --hub, shaft, bevel
what size needle for IM injections? - -- answer --2.5-3.8 cm
what size needle for SC injections? - -- answer --1-1.6 cm
blunt fill needle is used for - -- answer --vial withdrawal
blunt filter needle is used for - -- answer --ampoule withdrawal for IV bags & luer-
activated valves
how to perform the one hand scoop technique - -- answer --1) place cap on flat
surface, and remove hand from cap
2) w/ one hand, hold syringe & use needle to "scoop up" the cap
3) when cap covers needle completely, use other hand to secure cap from the
bottom.
ampules - -- answer --contain single doses of medication in a liquid. made up of
glass w/ a constricted neck that *must be snapped off to access the medication*
