Questions and Complete Solutions
Graded A+
What is primary intention wound healing? - Answer: Wound edges are well-approximated.
Place in order the wound healing process. - Answer: Hemostasis -> Inflammation -> Proliferate ->
Maturation
T/F: Serous-sanguinous drainage is blood mixed with pus. - Answer: False.
What is sometimes common to see in evisceration? - Answer: Fistulas, total separation of the wound,
caused by IAP (increased abdominal pressure)
What is a partial-thickness wound with loss of epidermis and some dermis? - Answer: Stage 2
What is a full-thickness wound with loss of skin and visible subcutaneous tissue? - Answer: Stage 3
What is a full-thickness wound with loss of the skin and visible bone and undermining? - Answer: Stage 4
What is a wound that has more than 75% of the wound bed covered? - Answer: Unstageable
The Braden Scale includes sensory, moisture, activity, and _________________? - Answer: Mobility,
nutrition, and friction/shear
What are some interventions to reduce the risk for skin injury? - Answer: Elevate the bed no greater
than 30-degrees; offload and reposition; control and inspect skin daily; encourage intake of protein,
calories, minerals, and fluids.
, T/F: The wound assessment should include location, size, color, wound base, drainage, edges, and peri-
wound skin. - Answer: True.
What is an ABI (ankle-brachial index) test? - Answer: Determines the atrial flow, determines inadequate
blood flow, determines delayed healing.
T/F: Hand washing is the best way to prevent infection. - Answer: True.
How much PSI is needed for proper wound irrigation? - Answer: 35-70 PSI
What is an example of a laceration? - Answer: Skin tear
What is an example of a portal of entry? - Answer: Blood
T/F: Virulence is the power of the pathogen to cause disease. - Answer: True.
T/F: Standard precaution should be used for all the patients. - Answer: True.
Who is at greater risk of become infected? - Answer: Elderly, those taking steroids, HIV patients
The five cardinal signs of inflammation: - Answer: Warmth, erythema (redness), pain, decreased
function, edema
T/F: Cytokines activate the inflammatory process? - Answer: True.
What happens to lymphocyte cells for someone with HIV? - Answer: CD8+T-cells are normal and CD4+T-
cells are low
What are things a patient who is immuno-compromised should avoid? - Answer: Fresh flowers or plants;
raw meat, fruits, and vegetables; avoid crowds