NSG-300 EXAM 2 Q AND A

NSG-
300 Topic 8 Medication Administratio
xc xc xc xc


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NSG-300 EXAM 2 Q AND A

whatxcplacesxcpatientsxcatxcriskxcforxcpressurexculcers/impairedxcskinxcintegrityxc-xcanswer--
pressurexcintensity,xcpressurexcduration,xctissuexctolerance,xcimpairedxcsensoryxcperception,xcimpairedxcmobility,xcalter
onxcinxcLOC,xcshear,xcfriction,xcmoisture

layersxcofxcthexcskinxc-xcanswer--epidermis,xcdermisxc(collagen)

body'sxcdefensesxcagainstxcinfectionxc-xcanswer--normalxcflora,xcinflammatoryxcresponse,xcimmunexcresponse

comprehensivexcwoundxcassessmentxc-xcanswer---
ongoingxcassessmentxcfromxctimexcofxcinjury,xcwoundxccare,xcanyxcconditionxcchanges,xcandxconxcscheduledxcbasis
-Importantxctoxcincludexccausexcofxcinjury,xchistoryxcofxcwound,xctreatment,xcdescription,xcresponsexctoxctherapy
-Bradenxcscale:xcassessesxcriskxcforxcpressure/skinxcinjuryxceveryxcshift

BradenxcScalexc-xcanswer--
assessesxcriskxcforxcdevelopingxcpressurexculcers;xcincludesxcpatient'sxcsensoryxcperception,xcmoisture,xcactivity,xcmob
y,xcnutrition,xcfrictionxcandxcshear;xcthexclowerxcthexcnumberxcthexchigherxcthexcrisk
>9=xcveryxchighxcrisk
10-12=xchighxcrisk
13-14=xcmoderatexcrisk
15-18=xcmildxcrisk
19-23=xcgenerallyxcnotxcatxcrisk

typexc1xculcersxc-xcanswer--skinxcisxcintactxcbutxcmayxcbexcredxcorxcpinkxcandxcwarmxctoxcthexctouch;xcnoxcblanching
-forxcPOC,xctherexcmayxcbexcnoxcnoticeablexcblanchingxcbutxcskinxccolorxcmayxcvary

typexc2xculcersxc-xcanswer--partial-thicknessxclossxcofxcdermis;xcshallowxcbrokenxcskin;xcred-pinkxcwoundxcbed

typexc3xculcersxc-xcanswer--full-thicknessxctissuexclossxcwithxcvisiblexcfatxc(subcutaneousxclayer);xcpale-
yellowxccolor;xcmayxcincludexcsloughxcbutxcdoesxcnotxcobstructxcviewxcofxcdepthxcofxcinjury

typexc4xculcersxc-xcanswer--full-
thicknessxctissuexclossxcwithxcexposedxcbone,xcmuscle,xcorxctendon.xcpossiblexctunnelingxcandxcundermining

unstageablexcpressurexculcerxc-xcanswer--basexcofxculcerxccoveredxcbyxcsloughxcand/
orxcescharxcinxcthexcwoundxcbedxcsoxcthexcdepthxcisxcunknown;xcexudate;

deepxctissuexcinjuryxc-xcanswer--Purplexcorxcmaroonxclocalizedxcareaxcofxcdiscoloredxcintactxcskinxcorxcblood-
filledxcblisterxcduexctoxcdamagexcofxcunderlyingxcsoftxctissuexcfromxcpressurexcand/orxcshear.

howxcshouldxcyouxccleanxcaxcwoundxc-xcanswer--fromxcleastxctoxcmostxccontaminated

escharxc-xcanswer--black,xcbrownxcorxcnecroticxctissuexcinxcwoundxcbed;xcneedsxctoxcbexcremovedxcbeforexchealing


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, NSG-
300 Topic 8 Medication Administratio
xc xc xc xc

sloughxc-xc n
answer--stringy pale-
xc

yellowishxctissuexcthatxclaysxcinxcthexcwoundxcbed;xcneedsxctoxcbexcremovedxcbeforexchealing

ifxcaxcpatientxchasxcslough,xceschar,xcandxcinfectiousxcexudatexcwhichxconexcwouldxcyouxcbexcmostxcconcernedxcaboutxc-
xcanswer--infectiousxcexudate



factorsxcinfluencingxcheatxcandxccoldxctolerancexc-xcanswer--Exposurexctime
Exposedxcskin
Temperature
Age
Perceptionxcofxcsensoryxcstimuli

assessmentxcforxcpressurexculcersxcincludesxc-xcanswer--location,xcstagingxc(depth),xctypexcandxc
%xcofxctissuexcinxcwoundxcbed,xcwoundxcdimensionsxc(includingxctunneling),xcexudatexcdescriptionxc(ifxcodorxcisxcpresent
andxcconditionxcofxcsurroundingxcskin

whyxcisxcdepthxcofxcanxculcerxcimportantxc-xcanswer--becausexcthexcwoundxchealsxcinside-out

granulationxctissuexc-xcanswer--
good,xcfreshxctissuexcthatxcformsxcduringxcthexchealingxcofxcaxcwoundxc(woundxcbedxcwillxcbexcred,xcmoist,xcandxcshiny)

Howxcdoesxcaxcpartialxcthicknessxcwoundxcheal?xc-xcanswer--byxcregenerationxc(scratchxcorxcabrasion)
-inflammatoryxcresponse:xcredness/swellingxctoxcareaxcwithxcmoderatexcserousxcexudate.xc1stxc24hrsxcafterxcwounding
-
epithelialxcproliferationxc(reproduction):xcstartsxcatxcwoundxcedgesxcandxcepidermalxccellsxcliningxcappendagesxc(quickxc
surfacing)
-
epithelialxcmigration:xcepithelialxccellsxconlyxcmigratexcinxcaxcmoistxcenvironment.xcinxcdryxcwound,xcthexccellsxcmovexcdow
cintoxcaxcmoistxclevelxcbeforexcresurfacingxccanxchappen

-reestablishmentxcofxcepidermalxclayers:xccellsxcslowlyxcestablishxcnormalxcthicknessxcandxcappearxcasxcdry,xcpinkxctissu

Howxcdoesxcaxcfullxcthicknessxcwoundxcheal?xc-xcanswer--byxcformingxcnewxctissue/
scarxcformation,xcwhichxctakesxclongerxc(pressurexculcers)
-hemostasis:xcinjuredxcvesselsxcconstrictxcandxcplateletsxcgatherxctoxcstopxcbleeding
-
inflammation:xcdamagedxctissuexcandxcmastxccellsxcsecretexchistaminexc(vasodilationxcofxcsurroundingxccapillariesxcand
movementxcofxcserumxcandxcWBCsxcintoxcdamagedxctissue)
-
proliferation:xcthexcvascularxcbedxcisxcreestablishedxc(granulationxctissue),xcthexcareaxcisxcfilledxcwithxcreplacementxctissu
c(collagen,xccontraction,xcandxcgranulationxctissue),xcandxcthexcsurfacexcisxcrepairedxc(epithelialization)

-
maturation:xcThexccollagenxcscarxccontinuesxctoxcreorganizexcandxcgainxcstrengthxcforxcseveralxcmonths.xcCollagenxcfibe
cundergoxcremodelingxcorxcreorganizationxcbeforexcassumingxctheirxcnormalxcappearance



primaryxcintentionxc-xcanswer--woundxcthatxcisxcclosed/
approximated;xclittlexctissuexcloss;xclowxcriskxcofxcinfection;xcquickxchealingxcwithxcnoxcscarxcusuallyxc(surgicalxcincision)

secondaryxcintentionxc-xcanswer--
axcwoundxcwithxclossxcofxctissue;xcwoundxcisxcnotxcapproximated;xchavexctoxchealxcfromxcthexcinside-
out;xcifxcscarringxcisxcsevere,xclossxcofxctissuexcfunctionxcmayxcbexcpermanentxc(pressurexculcers,xcsurgicalxcwoundxcthatx
asxctissuexcloss)
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, NSG-
300 Topic 8 Medication Administratio
xc xc xc xc


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tertiaryxcintentionxc-xcanswer--
Woundxcthatxcisxcleftxcopenxcforxcseveralxcdays,xcthenxcwoundxcedgesxcarexcapproximated;xcdoctorxccanxcmonitorxcstatus
fxcwound

complicationsxcofxcwoundxchealingxc-xcanswer--hemorrhage,xcinfection,xcdehiscence,xcevisceration

CMSxc-xcanswer--
createdxcpolicyxcforxchospitalsxctoxcnoxclongerxcreceivexcadditionalxcreimbursementxcforxccarexcrelatedxctoxceightxcconditio
sxctoxcimprovexcqualityxcofxchealthxccare

signsxcandxcsymptomsxcofxcwoundxcinfectionxc-xcanswer--Contaminatedxcorxctraumaticxcwounds:xc2-3xcdays
Postxcopxcsurgicalxcwound:xc4-5xcdays
Fever,xctendernessxcandxcpainxcatxcwoundxcsite
ElevatedxcWBCxccount
Woundxcedgesxcappearxcinflamed
Drainagexcmayxcbexcpresent:xcodorousxcandxcpurulentxc(yellow,xcgreen,xcorxcbrown)
Dehiscencexc
Evisceration

whatxcisxcneededxcforxcwoundxchealingxc-xcanswer--proteinxc(albumin)

factorsxcinfluencingxcpressurexculcerxcformationxcandxcwoundxchealingxc-xcanswer---nutrition
-tissuexcperfusion
-infection
-age
-psychosocialxcimpactsxc(bodyxcimage)

whenxcshouldxcyouxcgivexcanxcanalgesicxc-xcanswer--atxcleastxc30xcminutesxcbeforexcremovingxcaxcwoundxcdressing

ScientificxcMethodxcnursingxc-xcanswer--•identifyxcthexcproblem,
•collectxcdata,
•formulatexcaxcquestionxcorxchypothesis,
•testxcthexcquestionxcorxchypothesis,xcand
evaluatexcresultsxcofxcthexctestxcorxcstudy.

Withxcdrainage,xcwhatxcshouldxcyouxcassessxc-xcanswer--
amount,xccolor,xcodor,xcandxcconsistencyxc(ifxcdrainagexcisxcpungentxcorxcstrong,xcsuspectxcinfection)

Thexcusexcofxcdiagnosticxcreasoningxcinvolvesxcaxcrigorousxcapproachxctoxcclinicalxcpracticexcandxcdemonstratesxcthatxcc
calxcthinkingxccannotxcbexcdonexc________xc-xcanswer--haphazardly

Jackson-Prattxcdrainxc-xcanswer--hollowxcbulb-likexcdevicexcusedxctoxccollectxcdrainage;xcneedsxcgentle-
negativexcsuctionxc(squeezexcbeforexcyouxctightenxcthexccap)

whatxcisxcthexcpurposexcofxcthexcnursingxcprocessxc-xcanswer--
toxcdxxcandxctxxchumanxcresponsesxctoxcactualxcorxcpotentialxchealthxcproblems.

nursingxcinterventionsxcforxcthexcpreventionxcofxcpressurexculcersxc-xcanswer---
skinxccarexcandxcmanagementxcofxcincontinencexc
-mechanicalxcloadingxcandxcsupportxcdevices
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