NURS 356 Final Exam || with 100% Correct Answers.

NURS 356 Final Exam || with 100% Correct Answers.


Stage 1 Pressure Ulcer correct answers Skin is intact
When skin is pressed, it does not turn a lighter color (nonblanchable)
Primary goal: Prevent skin breakage


Stage 2 Pressure Ulcer correct answers Shallow, open ulcer
Can be a blister with serous or serosangineous fluid
Partial-thickness loss of epidermis
Red/pink wound bed


Stage 3 Pressure Ulcer correct answers Full-thickness tissue loss
May see subcutaneous fat
Sloughing may be present (shedding of cells)
Eschar may be present (dry, dark scab- dead tissue)
Possible undermining and tunneling


Stage 4 Pressure Ulcer correct answers Full-thickness tissue loss
Exposed bone, tendon, or muscle
Possible slough or eschar
Often undermining & tunneling


Unstageable Pressure Ulcer correct answers Base of wound is not visible
Full-thickness tissue loss
Completely obscured by slough or eschar
Necrotic tissue

, *Whenever there is necrosis, eschar --> unstageable!!! *


Any alteration in skin integrity? correct answers A wound


Types of Drainage correct answers Serous: clear fluid, or slightly white or yellow


Serosanguinous: serous with a little blood


Sanguineous: red blood


Purulent: white pus, thick can be also yellow, green, tan, brown


Complications of wound healing correct answers Hemorrhage: internal or external; 24-48 hrs
after injury


Infection: purulent drainage or positive culture


Dehiscence


Evisceration


Dehiscence correct answers -Layers of skin and tissue separate
-Obesity, increased pressure


Evisceration correct answers -Visceral organs come through the wound opening
-Surgical emergency