PPNC Exam 1 Module 3 UPDATED
ACTUAL Exam Questions and CORRECT
Answers
planning - CORRECT ANSWER - includes identification of priorities and the
determination of appropriate client-specific outcomes and interventions
SMART outcomes - CORRECT ANSWER - Specific
Measurable
Attainable
Realistic
Timed
interventions - CORRECT ANSWER - direct nursing care; can be independent
(autonomous actions initiated by the nurse) or collaborative (may require provider's order)
UF health fall predictive model - CORRECT ANSWER - calculates a score every hour
-score changes every hour with changes in patient status
-variables taken into account are medication administration, labs, age, gender, length of stay etc
which of the following nursing actions reduce tissue damage from shearing? Select all the apply
A. use a transfer device
B. elevate HOB when transferring a client
C. flatten HOB when repositioning a client
D. raise HOB to 60 degrees when client is supine
E. raise HOB to 30 degrees when client is supine - CORRECT ANSWER - A. use a
transfer device
C. flatten HOB when repositioning a client
, E. raise HOB to 30 degrees when client is supine
shear force - CORRECT ANSWER - the sliding movement of skin and SQ tissue while
the underlying muscle and bone are stationary
friction - CORRECT ANSWER - the force of 2 surfaces moving across each other -- this
affects the top layer of skin--epidermis, rather than the deeper tissue
deep tissue pressure injury (DTPI) - CORRECT ANSWER - persistent non-blanchable
deep red, maroon, or purple discoloration
granulation tissue - CORRECT ANSWER - the tissue that normally forms during the
healing of a wound (good sign)
slough - CORRECT ANSWER - stringy substance attached to wound bed, eventually must
be removed by qualified health care provider or by means of an appropriate wound dressing
before the wound is able to heal
eschar - CORRECT ANSWER - black, brown, tan, or necrotic tissue, needs to be removed
before healing can occur
exudate - CORRECT ANSWER - fluid, such as pus, that leaks out of an infected wound
-thicker white/tan
-pus
A patient is admitted to a rehabilitation facility for cardiac rehabilitation following open heart
surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with a
one-person assist in the hospital before transfer. The patient has a history of hypertension. His
wife accompanies him at the time of transfer. Which of the following assessment data would you
collect for this patient? (Select all that apply.)
1. Condition of surgical wound
ACTUAL Exam Questions and CORRECT
Answers
planning - CORRECT ANSWER - includes identification of priorities and the
determination of appropriate client-specific outcomes and interventions
SMART outcomes - CORRECT ANSWER - Specific
Measurable
Attainable
Realistic
Timed
interventions - CORRECT ANSWER - direct nursing care; can be independent
(autonomous actions initiated by the nurse) or collaborative (may require provider's order)
UF health fall predictive model - CORRECT ANSWER - calculates a score every hour
-score changes every hour with changes in patient status
-variables taken into account are medication administration, labs, age, gender, length of stay etc
which of the following nursing actions reduce tissue damage from shearing? Select all the apply
A. use a transfer device
B. elevate HOB when transferring a client
C. flatten HOB when repositioning a client
D. raise HOB to 60 degrees when client is supine
E. raise HOB to 30 degrees when client is supine - CORRECT ANSWER - A. use a
transfer device
C. flatten HOB when repositioning a client
, E. raise HOB to 30 degrees when client is supine
shear force - CORRECT ANSWER - the sliding movement of skin and SQ tissue while
the underlying muscle and bone are stationary
friction - CORRECT ANSWER - the force of 2 surfaces moving across each other -- this
affects the top layer of skin--epidermis, rather than the deeper tissue
deep tissue pressure injury (DTPI) - CORRECT ANSWER - persistent non-blanchable
deep red, maroon, or purple discoloration
granulation tissue - CORRECT ANSWER - the tissue that normally forms during the
healing of a wound (good sign)
slough - CORRECT ANSWER - stringy substance attached to wound bed, eventually must
be removed by qualified health care provider or by means of an appropriate wound dressing
before the wound is able to heal
eschar - CORRECT ANSWER - black, brown, tan, or necrotic tissue, needs to be removed
before healing can occur
exudate - CORRECT ANSWER - fluid, such as pus, that leaks out of an infected wound
-thicker white/tan
-pus
A patient is admitted to a rehabilitation facility for cardiac rehabilitation following open heart
surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with a
one-person assist in the hospital before transfer. The patient has a history of hypertension. His
wife accompanies him at the time of transfer. Which of the following assessment data would you
collect for this patient? (Select all that apply.)
1. Condition of surgical wound
