Nurs 1100 Exam 2 Study Guide Questions With Complete
Solutions
How are wounds treated after debridement?
Initially as a yellow wound, then as healing progresses, as a red
wound
wound culture
when obtaining a wound specimen for culture, always clean the
wound 1st using 0.9% sodium chloride (normal saline) or a
nonantimicrobial cleaner
What is the Braden Scale used for?
To assess risk for pressure injury
When is the Braden Scale typically done?
On admission
How is the Braden Scale score obtained?
By adding up points from different categories
What interventions are initiated based on the Braden Scale?
Interventions corresponding to the risk level
What is the total possible points on the Braden Scale?
23
What risk level is indicated by a score of 19-23 on the Braden
Scale?
,Not at Risk
What risk level is indicated by a score of 10-12 on the Braden
Scale?
High risk
What risk level is indicated by a score less than or equal to 9 on
the Braden Scale?
Very high risk
braden scale assessment areas
❖ Assessment areas: o Sensory Perception o Moisture o
Activity (degree of physical activity) o Mobility (ability to
change position) o Nutrition o Friction and Shear
apply moisture barrier on patients with?
urinary incontinence
drainage systems (used to prevent fluid from accumulating)
open o Penrose drain and closed systems o Jackson-Pratt drain o
Hemovac drain
What is a Penrose drain?
A soft and flexible open drainage system without a collection
device
How does a Penrose drain promote drainage?
Passively, with drainage moving from the wound or surgical site
to the dressing
,How is a Penrose drain secured to prevent slipping back into the
incised area?
A sterile, large safety pin is often attached to the outer portion
What is the procedure for shortening a Penrose drain daily?
Grasp the end with sterile forceps, pull it out a short distance
with a twisting motion, cut off the end with sterile scissors, and
place a new sterile pin at the base
Why is care necessary to prevent dislodging a Penrose drain
during dressing changes?
To maintain proper drainage and prevent complications
What does V.A.C. stand for in wound care?
Vacuum-assisted closure
How does Negative-Pressure Wound Therapy promote wound
healing?
By applying negative pressure on the wound bed
What are the benefits of using Negative-Pressure Wound
Therapy?
Reduces bacteria, removes excess drainage, provides a moist
environment, stimulates blood flow and new blood vessel
growth
What are examples of closed drainage systems?
Examples of closed drainage systems include Jackson-Pratt
drainage tubes and Hemovacs.
, Why are drainage tubes in closed drainage systems usually
sutured to the skin?
Drainage tubes in closed drainage systems are usually sutured to
the skin to secure them in place.
What are the benefits of a closed drainage system?
A closed drainage system prevents microorganisms from
entering the wound from saturated dressings and allows accurate
measurement of drainage.
How should a closed drainage system be maintained?
A closed drainage system must be emptied and the suction
reestablished according to the directions for each device, usually
by compressing the container while the port is open and then
closing the port after compression.
What does 'A' stand for in the skin cancer mnemonic for
malignant melanoma?
Asymmetry - One side of the mole is different from the other
What does 'B' stand for in the skin cancer mnemonic for
malignant melanoma?
Borders - Edges are irregular, ragged, notched, or blurred
What does 'C' stand for in the skin cancer mnemonic for
malignant melanoma?
Color - Variation or change in color, especially blue or black
What does 'D' stand for in the skin cancer mnemonic for
malignant melanoma?
Solutions
How are wounds treated after debridement?
Initially as a yellow wound, then as healing progresses, as a red
wound
wound culture
when obtaining a wound specimen for culture, always clean the
wound 1st using 0.9% sodium chloride (normal saline) or a
nonantimicrobial cleaner
What is the Braden Scale used for?
To assess risk for pressure injury
When is the Braden Scale typically done?
On admission
How is the Braden Scale score obtained?
By adding up points from different categories
What interventions are initiated based on the Braden Scale?
Interventions corresponding to the risk level
What is the total possible points on the Braden Scale?
23
What risk level is indicated by a score of 19-23 on the Braden
Scale?
,Not at Risk
What risk level is indicated by a score of 10-12 on the Braden
Scale?
High risk
What risk level is indicated by a score less than or equal to 9 on
the Braden Scale?
Very high risk
braden scale assessment areas
❖ Assessment areas: o Sensory Perception o Moisture o
Activity (degree of physical activity) o Mobility (ability to
change position) o Nutrition o Friction and Shear
apply moisture barrier on patients with?
urinary incontinence
drainage systems (used to prevent fluid from accumulating)
open o Penrose drain and closed systems o Jackson-Pratt drain o
Hemovac drain
What is a Penrose drain?
A soft and flexible open drainage system without a collection
device
How does a Penrose drain promote drainage?
Passively, with drainage moving from the wound or surgical site
to the dressing
,How is a Penrose drain secured to prevent slipping back into the
incised area?
A sterile, large safety pin is often attached to the outer portion
What is the procedure for shortening a Penrose drain daily?
Grasp the end with sterile forceps, pull it out a short distance
with a twisting motion, cut off the end with sterile scissors, and
place a new sterile pin at the base
Why is care necessary to prevent dislodging a Penrose drain
during dressing changes?
To maintain proper drainage and prevent complications
What does V.A.C. stand for in wound care?
Vacuum-assisted closure
How does Negative-Pressure Wound Therapy promote wound
healing?
By applying negative pressure on the wound bed
What are the benefits of using Negative-Pressure Wound
Therapy?
Reduces bacteria, removes excess drainage, provides a moist
environment, stimulates blood flow and new blood vessel
growth
What are examples of closed drainage systems?
Examples of closed drainage systems include Jackson-Pratt
drainage tubes and Hemovacs.
, Why are drainage tubes in closed drainage systems usually
sutured to the skin?
Drainage tubes in closed drainage systems are usually sutured to
the skin to secure them in place.
What are the benefits of a closed drainage system?
A closed drainage system prevents microorganisms from
entering the wound from saturated dressings and allows accurate
measurement of drainage.
How should a closed drainage system be maintained?
A closed drainage system must be emptied and the suction
reestablished according to the directions for each device, usually
by compressing the container while the port is open and then
closing the port after compression.
What does 'A' stand for in the skin cancer mnemonic for
malignant melanoma?
Asymmetry - One side of the mole is different from the other
What does 'B' stand for in the skin cancer mnemonic for
malignant melanoma?
Borders - Edges are irregular, ragged, notched, or blurred
What does 'C' stand for in the skin cancer mnemonic for
malignant melanoma?
Color - Variation or change in color, especially blue or black
What does 'D' stand for in the skin cancer mnemonic for
malignant melanoma?
