Galen Nur 155 Exam 3
1. Types of wounds Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
2. transparent film autolytic debridement, semi-permeable allows skin to
breathe.
uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears
3. how do you apply an abdominal start at typhoid, fasten from the bottom up
binder? used for support to keep dressing intact
remove every two hours to asses underlying skin and
wound
4. Risk factors for pressure ulcers 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
5. Signs of infected pressure ulcer? Change in color, odor, or drainage. Sever infections cause
fever and increased WBC.
6. During your assessment of a Non-blachable
new patient, the nurse notices a No opening
Stage I pressure ulcer, what are
the signs that this nurse is cor-
, Galen Nur 155 Exam 3
rect about this pressure ulcer be-
ing a stage one?
7. What do you do for a stage I Apply barrier creams
pressure ulcer? Reposition patient Q2hr
8. As you assess your new patient Stage II
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?
9. What type of dressing do you use Mepaplex or Duoderm
for a stage II pressure ulcer?
10. Full thickness skin loss, involving Stage III
damage or necrosis of subcuta-
neous is what stage pressure ul-
cer?
11. Full thickness skin loss with tis- Stage IV
sue necrosis, damage to the
muscle and bone, wound goes
through nerves and not painful
with tunneling present, which
stage is this wound?
12. Treating pressure ulcers Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position change
use assistive devices
, Galen Nur 155 Exam 3
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
ROM 3reps 2x daily
13. What is regeneration? replacement of destroyed tissue by the same kind of cells
14. Primary intention healing tissue surfaces are approximated (closed) and there is
minimal or no tissue loss, formation of minimal granula-
tion tissue and scarring
15. Secondary intention healing 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 infec-
tion
16. tertiary intention Wounds that are left open purposely for 3-5 days to allow
edema and infection to resolve.
17. serous clear, watery plasma
18. purulent containing pus, milky like
19. sanguineous dark bloody drainage
20. Serosanguineous bright red blood
21. Purosanguineous pus in the blood
22. When should you use heat ther- Vasodilation
apy? Chronic
Increase capillary permeability, cellular metabolism, in-
flammation
musculoskeletal problems
, Galen Nur 155 Exam 3
joint stiffness
arthritis
contractures and back pain
23. When do you use cold therapy? Vasoconstriction
acute pain
often used for sport injury (sprains, strains, fractures)
decreased capillary permeability, cellular metabolism, in-
flammation
24. Factors that affect respiratory Age
function? Environment
lifestyle
health status
medications
stress
25. eupnea normal breathing
26. Tachypnea rapid breathing
27. bradypnea slow breathing
28. apena absence of breathing
29. hypoventilation very shallow breathing, may cause increased levels of car-
bon dioxide. or high levels of oxygen
30. Hyperventilation very rapid breathing more CO2 is eliminated than provid-
ed.
31. orthopnea ability to breathe only in an upright position
32. Dyspena difficulty breathing
1. Types of wounds Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
2. transparent film autolytic debridement, semi-permeable allows skin to
breathe.
uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears
3. how do you apply an abdominal start at typhoid, fasten from the bottom up
binder? used for support to keep dressing intact
remove every two hours to asses underlying skin and
wound
4. Risk factors for pressure ulcers 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
5. Signs of infected pressure ulcer? Change in color, odor, or drainage. Sever infections cause
fever and increased WBC.
6. During your assessment of a Non-blachable
new patient, the nurse notices a No opening
Stage I pressure ulcer, what are
the signs that this nurse is cor-
, Galen Nur 155 Exam 3
rect about this pressure ulcer be-
ing a stage one?
7. What do you do for a stage I Apply barrier creams
pressure ulcer? Reposition patient Q2hr
8. As you assess your new patient Stage II
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?
9. What type of dressing do you use Mepaplex or Duoderm
for a stage II pressure ulcer?
10. Full thickness skin loss, involving Stage III
damage or necrosis of subcuta-
neous is what stage pressure ul-
cer?
11. Full thickness skin loss with tis- Stage IV
sue necrosis, damage to the
muscle and bone, wound goes
through nerves and not painful
with tunneling present, which
stage is this wound?
12. Treating pressure ulcers Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position change
use assistive devices
, Galen Nur 155 Exam 3
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
ROM 3reps 2x daily
13. What is regeneration? replacement of destroyed tissue by the same kind of cells
14. Primary intention healing tissue surfaces are approximated (closed) and there is
minimal or no tissue loss, formation of minimal granula-
tion tissue and scarring
15. Secondary intention healing 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 infec-
tion
16. tertiary intention Wounds that are left open purposely for 3-5 days to allow
edema and infection to resolve.
17. serous clear, watery plasma
18. purulent containing pus, milky like
19. sanguineous dark bloody drainage
20. Serosanguineous bright red blood
21. Purosanguineous pus in the blood
22. When should you use heat ther- Vasodilation
apy? Chronic
Increase capillary permeability, cellular metabolism, in-
flammation
musculoskeletal problems
, Galen Nur 155 Exam 3
joint stiffness
arthritis
contractures and back pain
23. When do you use cold therapy? Vasoconstriction
acute pain
often used for sport injury (sprains, strains, fractures)
decreased capillary permeability, cellular metabolism, in-
flammation
24. Factors that affect respiratory Age
function? Environment
lifestyle
health status
medications
stress
25. eupnea normal breathing
26. Tachypnea rapid breathing
27. bradypnea slow breathing
28. apena absence of breathing
29. hypoventilation very shallow breathing, may cause increased levels of car-
bon dioxide. or high levels of oxygen
30. Hyperventilation very rapid breathing more CO2 is eliminated than provid-
ed.
31. orthopnea ability to breathe only in an upright position
32. Dyspena difficulty breathing
