HONDROS NURSING NUR 150: EXAM 2 QUESTIONS WITH CORRECT ANSWERS

Stage 1 pressure ulcer CORRECT ANSWER Intact skin with nonblanchable redness Stage 2 pressure ulcer CORRECT ANSWER Partial loss of dermis. Shallow open ulcer, usually shiny, or dry. Red-pink wound bed without sloughing or bruising. Stage 3 pressure ulcer CORRECT ANSWER Full thickness tissue loss, subcutaneous fat may be visible. Possible undermining and tunneling. Stage 4 pressure ulcer CORRECT ANSWER Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present as well as undermining and tunneling. Unstageable pressure ulcer CORRECT ANSWER Full thickness tissue loss, wound base covered by slough and eschar therefor dull depth cannot be determined. Slough CORRECT ANSWER Fibrous tissue in wound bed that can be yellow, tan, gray, green, or brown. Nursing interventions to prevent pressure ulcers CORRECT ANSWER Reposition bed bound pt every two hours, instruct pt in wheelchair to shift their weight every hour. Use of cushions and barrier cream. Manage moisture, optimize nutrition and hydration. Cognition CORRECT ANSWER All the processes involv