Galen Nur 155 Exam 3 with 336 accurate
answers.
Galen Nur 155 Exam 3 with 336 accurate
answers.
Types of wounds - ANSWER Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
transparent film - ANSWER autolytic debridement, semi-permeable allows skin to breathe.
uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears
how do you apply an abdominal binder? - ANSWER start at typhoid, fasten from the bottom up
used for support to keep dressing intact
remove every two hours to asses underlying skin and wound
Risk factors for pressure ulcers - ANSWER Fecal and unitary incontinence
Friction and shearing
immobility
inadequate nutrition (decreased protein, Vitamin C, zinc)
Decreased mental status
excessive body heat (moisture)
advanced age
chronic conditions
Diminished sensation
Incorrect positioning
,Galen Nur 155 Exam 3 with 336 accurate
answers.
Signs of infected pressure ulcer? - ANSWER Change in color, odor, or drainage. Sever infections cause
fever and increased WBC.
During your assessment of a new patient, the nurse notices a Stage I pressure ulcer, what are the signs
that this nurse is correct about this pressure ulcer being a stage one? - ANSWER Non-blachable
No opening
What do you do for a stage I pressure ulcer? - ANSWER Apply barrier creams
Reposition patient Q2hr
As you assess your new patient you notice a sore on a bony premise that is blister-like, with partial
thickness skin loss, pt is complaining of pain where the wound is present which stage is this pressure
ulcer? - ANSWER Stage II
What type of dressing do you use for a stage II pressure ulcer? - ANSWER Mepaplex or Duoderm
Full thickness skin loss, involving damage or necrosis of subcutaneous is what stage pressure ulcer? -
ANSWER Stage III
Full thickness skin loss with tissue necrosis, damage to the muscle and bone, wound goes through
nerves and not painful with tunneling present, which stage is this wound? - ANSWER Stage IV
Treating pressure ulcers - ANSWER Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position change
use assistive devices
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
,Galen Nur 155 Exam 3 with 336 accurate
answers.
ROM 3reps 2x daily
What is regeneration? - ANSWER replacement of destroyed tissue by the same kind of cells
Primary intention healing - ANSWER tissue surfaces are approximated (closed) and there is minimal or
no tissue loss, formation of minimal granulation tissue and scarring
Secondary intention healing - ANSWER wound in which the tissue surfaces are not approximated and
there is extensive tissue loss; formation of excessive granulation tissue and scarring and greater risk of
infection
tertiary intention - ANSWER Wounds that are left open purposely for 3-5 days to allow edema and
infection to resolve.
serous - ANSWER clear, watery plasma
purulent - ANSWER containing pus, milky like
sanguineous - ANSWER dark bloody drainage
Serosanguineous - ANSWER bright red blood
Purosanguineous - ANSWER pus in the blood
When should you use heat therapy? - ANSWER Vasodilation
Chronic
Increase capillary permeability, cellular metabolism, inflammation
musculoskeletal problems
joint stiffness
, Galen Nur 155 Exam 3 with 336 accurate
answers.
arthritis
contractures and back pain
When do you use cold therapy? - ANSWER Vasoconstriction
acute pain
often used for sport injury (sprains, strains, fractures)
decreased capillary permeability, cellular metabolism, inflammation
Factors that affect respiratory function? - ANSWER Age
Environment
lifestyle
health status
medications
stress
eupnea - ANSWER normal breathing
Tachypnea - ANSWER rapid breathing
bradypnea - ANSWER slow breathing
apena - ANSWER absence of breathing
hypoventilation - ANSWER very shallow breathing, may cause increased levels of carbon dioxide. or high
levels of oxygen
Hyperventilation - ANSWER very rapid breathing more CO2 is eliminated than provided.
answers.
Galen Nur 155 Exam 3 with 336 accurate
answers.
Types of wounds - ANSWER Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
transparent film - ANSWER autolytic debridement, semi-permeable allows skin to breathe.
uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears
how do you apply an abdominal binder? - ANSWER start at typhoid, fasten from the bottom up
used for support to keep dressing intact
remove every two hours to asses underlying skin and wound
Risk factors for pressure ulcers - ANSWER Fecal and unitary incontinence
Friction and shearing
immobility
inadequate nutrition (decreased protein, Vitamin C, zinc)
Decreased mental status
excessive body heat (moisture)
advanced age
chronic conditions
Diminished sensation
Incorrect positioning
,Galen Nur 155 Exam 3 with 336 accurate
answers.
Signs of infected pressure ulcer? - ANSWER Change in color, odor, or drainage. Sever infections cause
fever and increased WBC.
During your assessment of a new patient, the nurse notices a Stage I pressure ulcer, what are the signs
that this nurse is correct about this pressure ulcer being a stage one? - ANSWER Non-blachable
No opening
What do you do for a stage I pressure ulcer? - ANSWER Apply barrier creams
Reposition patient Q2hr
As you assess your new patient you notice a sore on a bony premise that is blister-like, with partial
thickness skin loss, pt is complaining of pain where the wound is present which stage is this pressure
ulcer? - ANSWER Stage II
What type of dressing do you use for a stage II pressure ulcer? - ANSWER Mepaplex or Duoderm
Full thickness skin loss, involving damage or necrosis of subcutaneous is what stage pressure ulcer? -
ANSWER Stage III
Full thickness skin loss with tissue necrosis, damage to the muscle and bone, wound goes through
nerves and not painful with tunneling present, which stage is this wound? - ANSWER Stage IV
Treating pressure ulcers - ANSWER Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position change
use assistive devices
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
,Galen Nur 155 Exam 3 with 336 accurate
answers.
ROM 3reps 2x daily
What is regeneration? - ANSWER replacement of destroyed tissue by the same kind of cells
Primary intention healing - ANSWER tissue surfaces are approximated (closed) and there is minimal or
no tissue loss, formation of minimal granulation tissue and scarring
Secondary intention healing - ANSWER wound in which the tissue surfaces are not approximated and
there is extensive tissue loss; formation of excessive granulation tissue and scarring and greater risk of
infection
tertiary intention - ANSWER Wounds that are left open purposely for 3-5 days to allow edema and
infection to resolve.
serous - ANSWER clear, watery plasma
purulent - ANSWER containing pus, milky like
sanguineous - ANSWER dark bloody drainage
Serosanguineous - ANSWER bright red blood
Purosanguineous - ANSWER pus in the blood
When should you use heat therapy? - ANSWER Vasodilation
Chronic
Increase capillary permeability, cellular metabolism, inflammation
musculoskeletal problems
joint stiffness
, Galen Nur 155 Exam 3 with 336 accurate
answers.
arthritis
contractures and back pain
When do you use cold therapy? - ANSWER Vasoconstriction
acute pain
often used for sport injury (sprains, strains, fractures)
decreased capillary permeability, cellular metabolism, inflammation
Factors that affect respiratory function? - ANSWER Age
Environment
lifestyle
health status
medications
stress
eupnea - ANSWER normal breathing
Tachypnea - ANSWER rapid breathing
bradypnea - ANSWER slow breathing
apena - ANSWER absence of breathing
hypoventilation - ANSWER very shallow breathing, may cause increased levels of carbon dioxide. or high
levels of oxygen
Hyperventilation - ANSWER very rapid breathing more CO2 is eliminated than provided.
