NR 224 Fundamentals Exam 2 with all Correct & 100%
Verified Answers |Latest Update |Already Graded A+
Acute wounds ✔Correct Answer-trauma and surgical
Chronic ✔Correct Answer-vascular compromise
Pressure Ulcers ✔Correct Answer-Impaired skin integrity r/t unrelieved , prolonged pressure in
combination with shear or friction. (bed sores)
At risk pressure ulcer pt... ✔Correct Answer-Impaired sensory
Spinal cord injuries
Immobile patients
Shear/Friction
Moisture
Altered level of consciousness
Stage 1 pressure ulcer ✔Correct Answer-- Nonblanchable erythema
-Skin remains intact
Nursing Dx: (Ineffective tissue perfusion)
Stage II Pressure Ulcer ✔Correct Answer-- open skin wound
- shallow
- red/pink color
Stage III Pressure Ulcer ✔Correct Answer-- full thickness tissue loss
- subcutaneous fat visible
Stage IV Pressure Ulcer ✔Correct Answer-- exposed bone, muscle or tendon
- tunneling and undermining needed
Unstageable Pressure Ulcer ✔Correct Answer-- completely covered in slough
- some of wound can be necrotic
- difficult to stage
- after deprevement stage can be determined
Suspected Deep Tissue Ulcer ✔Correct Answer-purple localized area of discolored intact skin blood
filled blister.
-mushy
- warm or cool
Pressure Ulcer Assessment and documentation ✔Correct Answer-Location
Wound Bed
-Tunneling
-Undermining
-Granulation tissue
-Slough
-Eschar
Drainage
, Odor
Size
LxW
Depth
Pain
Dressing change
Dressing type
Cleaning solution
How the patient tolerated the procedure!
Undermining ✔Correct Answer-Caused by erosion under the wound edges
resulting in a large wound with a small opening.
Clock terms are used to describe the location of undermining ✔Correct Answer-12 o clock is
towards the head
Another name from necrotic? ✔Correct Answer-Eschar
Slough ✔Correct Answer--Soft yellow stringy substances attached to wound bed
-Must be removed
Eschar ✔Correct Answer-Black, brown, tan, or necrotic tissue
Serous drainage ✔Correct Answer-Thin, clear watery
- blister fluid filled
Serosanguineous drainage ✔Correct Answer-serous mixed with blood / pink color
Sanguineous ✔Correct Answer-Thin bright blood, clotting
Primary Intention Healing ✔Correct Answer-- edges are together
- minimal scarring
- surgery
Secondary Intention Healing ✔Correct Answer-- needs to heal from bottom up
- takes longer to heal
Partial thickness ✔Correct Answer-Shallow. Involves epithelialization.
Full thickness ✔Correct Answer-Extend into dermis. Involves granulation
inflammatory process takes.. ✔Correct Answer-4 to 6 days
Proliferative process takes.. ✔Correct Answer-Several weeksEpithelialization occurs
Remodeling/ maturation ✔Correct Answer-begins about 3 weeks after injury & can last over year
Desiccated Wound ✔Correct Answer-Extreme dryness in the wound, dry/flaky
Slows wound healing
Macerated Wound ✔Correct Answer-Moist/wet
Verified Answers |Latest Update |Already Graded A+
Acute wounds ✔Correct Answer-trauma and surgical
Chronic ✔Correct Answer-vascular compromise
Pressure Ulcers ✔Correct Answer-Impaired skin integrity r/t unrelieved , prolonged pressure in
combination with shear or friction. (bed sores)
At risk pressure ulcer pt... ✔Correct Answer-Impaired sensory
Spinal cord injuries
Immobile patients
Shear/Friction
Moisture
Altered level of consciousness
Stage 1 pressure ulcer ✔Correct Answer-- Nonblanchable erythema
-Skin remains intact
Nursing Dx: (Ineffective tissue perfusion)
Stage II Pressure Ulcer ✔Correct Answer-- open skin wound
- shallow
- red/pink color
Stage III Pressure Ulcer ✔Correct Answer-- full thickness tissue loss
- subcutaneous fat visible
Stage IV Pressure Ulcer ✔Correct Answer-- exposed bone, muscle or tendon
- tunneling and undermining needed
Unstageable Pressure Ulcer ✔Correct Answer-- completely covered in slough
- some of wound can be necrotic
- difficult to stage
- after deprevement stage can be determined
Suspected Deep Tissue Ulcer ✔Correct Answer-purple localized area of discolored intact skin blood
filled blister.
-mushy
- warm or cool
Pressure Ulcer Assessment and documentation ✔Correct Answer-Location
Wound Bed
-Tunneling
-Undermining
-Granulation tissue
-Slough
-Eschar
Drainage
, Odor
Size
LxW
Depth
Pain
Dressing change
Dressing type
Cleaning solution
How the patient tolerated the procedure!
Undermining ✔Correct Answer-Caused by erosion under the wound edges
resulting in a large wound with a small opening.
Clock terms are used to describe the location of undermining ✔Correct Answer-12 o clock is
towards the head
Another name from necrotic? ✔Correct Answer-Eschar
Slough ✔Correct Answer--Soft yellow stringy substances attached to wound bed
-Must be removed
Eschar ✔Correct Answer-Black, brown, tan, or necrotic tissue
Serous drainage ✔Correct Answer-Thin, clear watery
- blister fluid filled
Serosanguineous drainage ✔Correct Answer-serous mixed with blood / pink color
Sanguineous ✔Correct Answer-Thin bright blood, clotting
Primary Intention Healing ✔Correct Answer-- edges are together
- minimal scarring
- surgery
Secondary Intention Healing ✔Correct Answer-- needs to heal from bottom up
- takes longer to heal
Partial thickness ✔Correct Answer-Shallow. Involves epithelialization.
Full thickness ✔Correct Answer-Extend into dermis. Involves granulation
inflammatory process takes.. ✔Correct Answer-4 to 6 days
Proliferative process takes.. ✔Correct Answer-Several weeksEpithelialization occurs
Remodeling/ maturation ✔Correct Answer-begins about 3 weeks after injury & can last over year
Desiccated Wound ✔Correct Answer-Extreme dryness in the wound, dry/flaky
Slows wound healing
Macerated Wound ✔Correct Answer-Moist/wet
