NSG-300 Exam 2 Questions And Answers (Verified And Updated)

NSG-300 Exam 2 Questions And Answers (Verified And Updated) What are 3 pressure related factors that contribute to pressure ulcer development? - answer1. Pressure Intensity 2. Pressure Duration 3. Tissue Tolerance How does pressure lead to tissue ischemia? - answerIf 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? - answertissue death Does blanching occur in dark skinned patients? - answerNo, blanching does not occur but color, texture and temp may differ from surrounding area What does pressure duration assess? - answerLow 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? - answerthe 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? - answer◦Impaired sensory perception ◦Impaired mobility ◦Alteration in LOC ◦Shear ◦Friction ◦Moisture What should the nurse look for when assessing a pressure injury? - answerWound location, staging, type and approximate percentage of tissue in wound bed, wound dimensions (sinus tracts and tunneling), exudate description and condition of surrounding skin stage 1 pressure injury - answerIntact skin with nonblanchable redness stage 2 pressure injury - answerpartial thickness skin loss involving epidermis, dermis or both and, shallow abrasion or open blister looking stage 3 pressure injury - answerfull thickness skin loss extending to SQ, crater looking stage 4 pressure injury - answerfull thickness with exposed bone, muscle or tendon and may have eschar What characteristics does stage 3 and 4 pressure injuries share? - answerThey may have slough, undermining and tunneling present A nurse states slough is present in a stage 3 pressure injury. What should the student nurse expect to see? - answerA yellow or white, stringy substance attached to wound bed A nurse states eschar is present in a stage 4 pressure injury. What should the student nurse expect to see? - answerbrown or black necrotic tissue Unstageable/Unclassified Pressure Ulcer - answerTissue loss but depth unknown because wound bed is obscured by slough and/or eschar A patient has an unstageable pressure ulcer but refuses treatment and states "it will heal on its own". What education should the nurse provide? - answerSlough and eschar must be removed by a clinician to determine the stage and in order for healing to occur suspected deep tissue injury - answerPurple 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 granulation tissue. What should the student nurse expect to see? - answerRed, moist tissue which indicates progression toward healing What should the nurse document when assessing exudate? - answerAmount, color, consistency and odor The student nurse sees an excess amount of exudate in the wound bed. What does this indicate? - answerThe presence of infection What should the nurse look for when assessing the periwound area? Why is it important? - answerRedness, warmth, signs of maceration and pain - presence of any of these factors indicates wound deterioration Why is wound classification important? - answerAllows a nurse to understand the risks associated with a wound and implications for healing How does a partial thickness wound heal? - answerHeals by regeneration How does a full thickness would heal? - answerHeals by forming new tissue which takes longer What are the three components involved in the healing process of a partial thickness wound? - answerInflammatory response, epithelial proliferation and migration, and reestablishment of epidermal layers A patient states keeping his wound exposed to air while allow his wound to heal quickly. What education should the nurse provide to the patient? - answerWounds heal faster in moist environments because epidermal cells only migrate across moist surfaces. Reestablishment of the epidermal layers - answerNew 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 of a full thickness wound? - answerHemostasis, inflammation, proliferation and maturation Primary intention healing - answerThe 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 Secondary infection healing - answerWound is left open until it becomes filed by scar tissue. It takes longer for a wound to heal by secondary intention increasing the chance of infection hemorrhage - answerbleeding from a wound site is normal during and immediately after initial trauma A nurse suspects internal bleeding. How would the nurses assess the patient to confirm her findings? - answerBy assessing for distention or swelling of the affected body part, change in type and amount of drainage from a surgical drain r signs of hypovolemic shock Hematoma - answerlocalized collection of blood underneath the tissue dihiscence - answerpartial or total separation of wound layers Evisceration - answerprotrusion of visceral organs through a wound opening What is the second most common health care associated infection? - answerwound infection What are the signs and symptoms of wound infection? - answerFever, tenderness and pain at wound site Elevated WBC count Wound edges appear inflamed Drainage may be present: odorous and purulent (yellow, green, or brown)