Answers
___ is responsible for the ability to absorb sun rays and skin pigment - ANS melanin
___ is a mineral that is found in any food that is orange and is the structure for skin cells -
ANS carotene
What are the 4 phases of wound healing? - ANS 1. hemostasis
2. inflammatory
3. proliferation
4. maturation
During the ___ phase of wound healing, blood clotting begins, exudate is formed, and swelling
and pain occur - ANS hemostasis
The ___ phase of wound healing lasts 2-3 days, WBC moves to wound, and a mild fever and
pain will be present - ANS inflammatory
The ___ phase of wound healing lasts several weeks and new tissue is built into wound space -
ANS proliferation
The ___ phase of wound healing can last between 21 days and 2 years and occurs once the
wound has closed - ANS Maturation
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,___ = removal of moisture
___ = excess moisture - ANS desiccation; maceration
___ discharge in a wound is cloudy and results from the accumulation of neutrophils -
ANS purulent
___ is a wound complication where there's separation of wound margins and poking out of
insides - ANS Dehiscence and evisceration
What are the 4 most common places for a pressure ulcer? - ANS occipital, sacrum, coccyx,
and back of heels
What are the factors affecting pressure injury development? - ANS External pressure - Bony
prominence
Friction - Two surfaces rub together
Shear - One layer of tissue slides over another
The ___ is used to assess a patient's risk for a pressure injury using their sensory perception,
moisture, activity, mobility, nutrition, and friction - ANS Braden skin score
Less than a ___ on the Braden skin score is considered high risk - ANS 18
___ is the degrading of tissue under the edge - ANS undermining
If a patient presents with non-blanchable erythema of intact skin and skin is fully intact, what
stage pressure ulcer is that? - ANS Stage 1
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, If a patient presents with a slightly broken top layer of skin and the underneath is pink, red, and
moist what stage pressure injury is that? - ANS Stage 2
If a patient presents with a pressure injury that extends to subcutaneous fat layer and has
slough/eschar present, what stage is that? - ANS Stage 3
If a patient presents with a pressure injury that exposes part of the muscle and has
slough/eschar present, what stage is that? - ANS Stage 4
If a patient has a pressure injury where full thickness skin and tissue loss which the extent of
tissue damage with ulcer cannot be confirmed due to being obscured by slough or eschar, what
stage is that? - ANS Unstageable
True or false: When cleaning a pressure injury you should use new gauze for each wipe and
clean from top to bottom and/or from the center to outside - ANS True
___ wound drainage is clear plasma and doesn't contain blood - ANS Serous
___ wound drainage looks like pus and contains dead neutrophils due to an infection -
ANS purulent
___ wound drainage may have some transparency but looks pink due to the presence of some
RBCs - ANS Serosanguineous
___ wound drainage cannot be seen through and is dark red - ANS Sanguineous
___ drain is a flexible tube that lets fluid drain from a surgical site and is considered a ___
drainage system - ANS Penrose; open
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