Nur 222

Nur 222 Exam with correct Answers Dermis - Correct Answer-Where is collagen located in the skin? Decubitis, bedsore - Correct Answer-What are 2 other names for pressure ulcers? pressure ulcer - Correct Answer-Localized injury to the skin underlying tissue Capillaries - Correct Answer-smallest vessel in body, located between arterioles and venules 5 to 10 microns - Correct Answer-What is the diameter of a capillary? 15 to 32 mmHg - Correct Answer-How much pressure in mmHg will occlude capillary blood flow? ischemia - Correct Answer-Low blood flow reactive hypermia - Correct Answer-occurs d/t visible oxyhemoglobin from increased blood flow to deprived area blanching - Correct Answer-when the skin is pressed and turns white impaired sensory perception, alterations on LOC, impaired mobility, shear, friction, moisture - Correct Answer-what are some risk factors for pressure ulcer development stage 1 - Correct Answer-intact skin with nonblanchable redness (reactive hypermia) stage2 - Correct Answer-partial-thickness skin loss involving epidermis, dermis, or both Stage 3 - Correct Answer-full thickness tissue loss with visible fat Stage 4 - Correct Answer-Full thickness tissue loss with exposed bone, muscle, or tendon unstagable - Correct Answer-when the wound cannot be seen well enough it is considered what primary intention - Correct Answer-most surgical wounds are healthy this way, stitched up, clean edges Secondary intention - Correct Answer-surgically created wound that is left open tertiary intention - Correct Answer-When resolution has occurred, the wound edges can be brought together (approximated) and the wound proceeds to heal. partial thickness - Correct Answer-inflammatory phase, epithelial proliferation & migration Full thickness - Correct Answer-inflammatory, proliferated phase and remodeling phase:scar is stronger than tissue it replaces hemmorage - Correct Answer-bleeding dehiscence - Correct Answer-when wound seperates evisceration - Correct Answer-medical emergency part og bowel protrudes outside of wound wound infection - Correct Answer-2nd most common type of HAI, heat, edema, purulence, redness, drainage Fistulas - Correct Answer-abnormal communication between one tube of the body to another tube of the body Braden Scale - Correct Answer-Predicting Pressure Ulcer Risk sensory perception, moisture, activity, mobility, nutrition, friction and shear - Correct Answer-what are some factors that influence the Braden scale 18 or lower - Correct Answer-what is considered high risk on the braden tissue perfusion - Correct Answer-how well blood is flowing to the tissue infection - Correct Answer-slows down healing process age - Correct Answer-thinner skin, immune system deteriorates over time is due to what perssure ulcer, color, type - Correct Answer-how do you classify a wound dehiscence, infection, evisceration - Correct Answer-what are 3 complications of wound healing? length, width, depth - Correct Answer-how do you measure a wound purulence - Correct Answer-puss/infection serous - Correct Answer-clear fluid, looks a straw color when dried on gauze serous sanguinous - Correct Answer-looks pink sanguineous - Correct Answer-looks browns when dried, made up of rbc Jackson pratt - Correct Answer-type of drain that can hold about 120mL sutures staples - Correct Answer-how can wounds be closedc debridement - Correct Answer-removable of nonviable, necrotic tissue protects a wound from microorganism contamination, aid in hemostasis - Correct Answer-what is the purpose of a dressing Antiseptics - Correct Answer-applied to living tissue, not for established infection, prophylactic use Disinfectants - Correct Answer-agent applied to objects, generally too harsh for living tissue DAKIN's solution - Correct Answer-diluted solution of bleach used on very foul smelling (decaying flesh), advanced ulcers 70% ethanol, iodine compunds, chlorine, chlorhexadine - Correct Answer-what are examples of antiseptics aldeydes, hydrogen peroxide, chlorine compunds - Correct Answer-what are examples of disinfectants Rest, ice, Compression, Elevation - Correct Answer-What is RICE documentation - Correct Answer-nursing process that produces a writeen account of pertinent patient data, clinical decisions and interventions, and how the patient responded communication - Correct Answer-tells the story of the patient, assessment findings, any interventions reimbursement - Correct Answer-hospital losing money if patient returns within 30 days with same diagnosis HITECH - Correct Answer-established provisions to promote meaningful use of health information technology (HIT) yo improve quality & value of health care SOAP - Correct Answer-Subjective, objective, assessment, plan SOAPIE - Correct Answer-Problem or nursing dx, interventions, evaluations Charting by exception - Correct Answer-charting that uses checklists, WDLs, more detailed documentation if not WDLs, adult ongoing assessment nursing informatics - Correct Answer-use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research Normal flora - Correct Answer-what control pathogens and aid in digestion primary defenses - Correct Answer-has to do with normal functioning of the body ex. not having intact skin, secretions, change in pH levels secondary defenses - Correct Answer-inflammatory response ex. labs like WBC, leukopenia - Correct Answer-too few blood cells - Correct Answer-What is the normal for WBC count Neutrophils - Correct Answer-highest component of WBCs Lymphocytes - Correct Answer-2nd highest component of WBCs Erythrocyte sedimentation rate - Correct Answer-tells you there is acute inflammation in the body iron level - Correct Answer-tells you if there is a chronic infection UTI - Correct Answer-one of the most common HAIs, associated with procedure, putting a catheter in bacterium and death - Correct Answer-what can a UTI lead to Pneumonia - Correct Answer-excess of fluid in the lungs, 7th leading cause of death worldwide