NUR 2050--EXAM 1 QUESTIONS WITH COMPLETE
SOLUTIONS
A person with an ileostomy is at risk for what? Correct Answers
water loss
A score of ≤12 on the Braden Scale is considered _____ level of
pressure ulcer risk. Correct Answers high risk
A score of 13-14 is considered _____ level of pressure ulcer
risk. Correct Answers moderate risk
A score of 15-16 is considered _____ level of pressure ulcer
risk. Correct Answers mild risk
After surgery, child birth, and catheter removal, when must a
patient void by? Correct Answers must void within 8 hours
After surgery, the stoma is _______. It ______ in size 6-8 weeks
after surgery. Correct Answers 1. edematous
2. reduces
An internal fecal management system is used for a patient with
_______ to help prevent skin breakdown. Correct Answers
diarrhea
Anuria is how much urine produced in 24 hours? Correct
Answers <100 mL
At what age is daytime bladder controlled? Correct Answers 2-
3 years old
,At what age is nighttime bladder controlled? Correct Answers
4-5 years old
At what amount does the normal adult feel the sensation to
urinate? Correct Answers 150-250 mL
Bladder training is used to treat which urinary incontinence?
Correct Answers OAB
Describe a stage 1 pressure ulcer/injury. Correct Answers --
NON-blanchable erythema of INTACT skin
--changes in sensation, temperature, or firmness
--color changes do NOT include purple or maroon
Describe a stage 2 pressure ulcer/injury. Correct Answers --
partial thickness loss of skin with exposed dermis
--wound bed is viable, pink or red, moist, and may also present
as an intact or ruptured serum-filled bister
--NO adipose tissue, NO granulation, NO slough, NO eschar
Describe a stage 3 pressure ulcer/injury. Correct Answers --
Full thickness loss of skin
--exposure of adipose tissue visible, granulation and epibole
often present
--slough and/or eschar may be visible
--undermining and tunneling may occur
--fascia, muscle, tendon, ligament, cartilage, and/or bone are
NOT exposed with a stage 3
--if slough or eschar obscures the extent of tissue loss its
considered "unstageable pressure injury"
, Describe a stage 4 pressure ulcer/injury. Correct Answers --
Full thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage, or bone in
the ulcer
--slough and/or eschar may be visible
--epibole, undermining, and/or tunneling often occur
--depth depending on location
--if slough or eschar obscures the extent of tissue loss its
considered "unstageable pressure injury"
Describe an unstageable pressure ulcer/injury. Correct Answers
--Obscured full thickness skin and tissue loss
--extent of tissue damage within the ulcer cannot be confirmed
due to slough or eschar
--if slough or eschar is removed, then a stage 3 or 4 pressure
ulcer/injury will be revealed
--stable eschar on the heel or ischemic limb should NOT be
softened or removed!!!!
Elevating the head of bed to no more than 30 degrees helps with
this? Correct Answers shearing
High air bed or low air bed; which causes dehydration? Correct
Answers high air bed
How are mucosal membrane pressure injuries staged? Correct
Answers they CANNOT be staged due to the anatomy of the
tissue
SOLUTIONS
A person with an ileostomy is at risk for what? Correct Answers
water loss
A score of ≤12 on the Braden Scale is considered _____ level of
pressure ulcer risk. Correct Answers high risk
A score of 13-14 is considered _____ level of pressure ulcer
risk. Correct Answers moderate risk
A score of 15-16 is considered _____ level of pressure ulcer
risk. Correct Answers mild risk
After surgery, child birth, and catheter removal, when must a
patient void by? Correct Answers must void within 8 hours
After surgery, the stoma is _______. It ______ in size 6-8 weeks
after surgery. Correct Answers 1. edematous
2. reduces
An internal fecal management system is used for a patient with
_______ to help prevent skin breakdown. Correct Answers
diarrhea
Anuria is how much urine produced in 24 hours? Correct
Answers <100 mL
At what age is daytime bladder controlled? Correct Answers 2-
3 years old
,At what age is nighttime bladder controlled? Correct Answers
4-5 years old
At what amount does the normal adult feel the sensation to
urinate? Correct Answers 150-250 mL
Bladder training is used to treat which urinary incontinence?
Correct Answers OAB
Describe a stage 1 pressure ulcer/injury. Correct Answers --
NON-blanchable erythema of INTACT skin
--changes in sensation, temperature, or firmness
--color changes do NOT include purple or maroon
Describe a stage 2 pressure ulcer/injury. Correct Answers --
partial thickness loss of skin with exposed dermis
--wound bed is viable, pink or red, moist, and may also present
as an intact or ruptured serum-filled bister
--NO adipose tissue, NO granulation, NO slough, NO eschar
Describe a stage 3 pressure ulcer/injury. Correct Answers --
Full thickness loss of skin
--exposure of adipose tissue visible, granulation and epibole
often present
--slough and/or eschar may be visible
--undermining and tunneling may occur
--fascia, muscle, tendon, ligament, cartilage, and/or bone are
NOT exposed with a stage 3
--if slough or eschar obscures the extent of tissue loss its
considered "unstageable pressure injury"
, Describe a stage 4 pressure ulcer/injury. Correct Answers --
Full thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage, or bone in
the ulcer
--slough and/or eschar may be visible
--epibole, undermining, and/or tunneling often occur
--depth depending on location
--if slough or eschar obscures the extent of tissue loss its
considered "unstageable pressure injury"
Describe an unstageable pressure ulcer/injury. Correct Answers
--Obscured full thickness skin and tissue loss
--extent of tissue damage within the ulcer cannot be confirmed
due to slough or eschar
--if slough or eschar is removed, then a stage 3 or 4 pressure
ulcer/injury will be revealed
--stable eschar on the heel or ischemic limb should NOT be
softened or removed!!!!
Elevating the head of bed to no more than 30 degrees helps with
this? Correct Answers shearing
High air bed or low air bed; which causes dehydration? Correct
Answers high air bed
How are mucosal membrane pressure injuries staged? Correct
Answers they CANNOT be staged due to the anatomy of the
tissue
