NSG-300 Exam 2 UPDATED ACTUAL Questions and CORRECT
Answers
What are 3 pressure related factors that contribute to 1. Pressure Intensity
pressure ulcer development? 2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? If pressure applied over a capillary exceeds normal capillary pressure and the
vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? tissue death
Does blanching occur in dark skinned patients? No, blanching does not occur but color, texture and temp may differ from
surrounding area
What does pressure duration assess? Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? the ability of tissue to endure pressure which is dependent on the integrity of the
tissue and supporting structures
What are risk factors of pressure injuries? ◦ Impaired sensory perception
◦ Impaired mobility
◦ Alteration in LOC
◦ Shear
◦ Friction
◦ Moisture
What should the nurse look for when assessing a Wound location, staging, type and approximate percentage of tissue in wound
pressure injury? bed, wound dimensions (sinus tracts and tunneling), exudate description and
condition of surrounding skin
stage 1 pressure injury Intact skin with nonblanchable redness
stage 2 pressure injury partial thickness skin loss involving epidermis, dermis or both and, shallow
abrasion or open blister looking
stage 3 pressure injury full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury full thickness with exposed bone, muscle or tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries They may have slough, undermining and tunneling present
share?
A nurse states slough is present in a stage 3 pressure A yellow or white, stringy substance attached to wound bed
injury. What should the student nurse expect to see?
, A nurse states eschar is present in a stage 4 pressure brown or black necrotic tissue
injury. What should the student nurse expect to see?
Unstageable/Unclassified Pressure Ulcer Tissue loss but depth unknown because wound bed is obscured by slough and/or
eschar
A patient has an unstageable pressure ulcer but refuses Slough and eschar must be removed by a clinician to determine the stage and in
treatment and states "it will heal on its own". What order for healing to occur
education should the nurse provide?
suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister
due to damage of underlying soft tissue from pressure and/or shear. Depth
unknown
A nurse is assessing a wound and notes the presence of Red, moist tissue which indicates progression toward healing
granulation tissue. What should the student nurse expect
to see?
What should the nurse document when assessing Amount, color, consistency and odor
exudate?
The student nurse sees an excess amount of exudate in The presence of infection
the wound bed. What does this indicate?
What should the nurse look for when assessing the Redness, warmth, signs of maceration and pain
periwound area? Why is it important? - presence of any of these factors indicates wound deterioration
Why is wound classification important? Allows a nurse to understand the risks associated with a wound and implications
for healing
How does a partial thickness wound heal? Heals by regeneration
How does a full thickness would heal? Heals by forming new tissue which takes longer
What are the three components involved in the healing Inflammatory response, epithelial proliferation and migration, and reestablishment
process of a partial thickness wound? of epidermal layers
A patient states keeping his wound exposed to air while Wounds heal faster in moist environments because epidermal cells only migrate
allow his wound to heal quickly. What education should across moist surfaces.
the nurse provide to the patient?
Reestablishment of the epidermal layers New epithelium is only a few cells thick. Cells slowly reestablish normal thickness
and appear as dry, pink tissue
What are the four stages involved in the healing process Hemostasis, inflammation, proliferation and maturation
of a full thickness wound?
Primary intention healing The skin edges are approximated, or closed, and the risk of infection is low.
Healing occurs quickly, with minimal scar formation, as long as infection and
secondary breakdown are prevented
Answers
What are 3 pressure related factors that contribute to 1. Pressure Intensity
pressure ulcer development? 2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? If pressure applied over a capillary exceeds normal capillary pressure and the
vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? tissue death
Does blanching occur in dark skinned patients? No, blanching does not occur but color, texture and temp may differ from
surrounding area
What does pressure duration assess? Low and extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue death
What is tissue tolerance? the ability of tissue to endure pressure which is dependent on the integrity of the
tissue and supporting structures
What are risk factors of pressure injuries? ◦ Impaired sensory perception
◦ Impaired mobility
◦ Alteration in LOC
◦ Shear
◦ Friction
◦ Moisture
What should the nurse look for when assessing a Wound location, staging, type and approximate percentage of tissue in wound
pressure injury? bed, wound dimensions (sinus tracts and tunneling), exudate description and
condition of surrounding skin
stage 1 pressure injury Intact skin with nonblanchable redness
stage 2 pressure injury partial thickness skin loss involving epidermis, dermis or both and, shallow
abrasion or open blister looking
stage 3 pressure injury full thickness skin loss extending to SQ, crater looking
stage 4 pressure injury full thickness with exposed bone, muscle or tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries They may have slough, undermining and tunneling present
share?
A nurse states slough is present in a stage 3 pressure A yellow or white, stringy substance attached to wound bed
injury. What should the student nurse expect to see?
, A nurse states eschar is present in a stage 4 pressure brown or black necrotic tissue
injury. What should the student nurse expect to see?
Unstageable/Unclassified Pressure Ulcer Tissue loss but depth unknown because wound bed is obscured by slough and/or
eschar
A patient has an unstageable pressure ulcer but refuses Slough and eschar must be removed by a clinician to determine the stage and in
treatment and states "it will heal on its own". What order for healing to occur
education should the nurse provide?
suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister
due to damage of underlying soft tissue from pressure and/or shear. Depth
unknown
A nurse is assessing a wound and notes the presence of Red, moist tissue which indicates progression toward healing
granulation tissue. What should the student nurse expect
to see?
What should the nurse document when assessing Amount, color, consistency and odor
exudate?
The student nurse sees an excess amount of exudate in The presence of infection
the wound bed. What does this indicate?
What should the nurse look for when assessing the Redness, warmth, signs of maceration and pain
periwound area? Why is it important? - presence of any of these factors indicates wound deterioration
Why is wound classification important? Allows a nurse to understand the risks associated with a wound and implications
for healing
How does a partial thickness wound heal? Heals by regeneration
How does a full thickness would heal? Heals by forming new tissue which takes longer
What are the three components involved in the healing Inflammatory response, epithelial proliferation and migration, and reestablishment
process of a partial thickness wound? of epidermal layers
A patient states keeping his wound exposed to air while Wounds heal faster in moist environments because epidermal cells only migrate
allow his wound to heal quickly. What education should across moist surfaces.
the nurse provide to the patient?
Reestablishment of the epidermal layers New epithelium is only a few cells thick. Cells slowly reestablish normal thickness
and appear as dry, pink tissue
What are the four stages involved in the healing process Hemostasis, inflammation, proliferation and maturation
of a full thickness wound?
Primary intention healing The skin edges are approximated, or closed, and the risk of infection is low.
Healing occurs quickly, with minimal scar formation, as long as infection and
secondary breakdown are prevented
