NFDN 2003 Final Review questions with
| | | | | |
correct answers |
SBAR |- |correct |answer |Its |a |framework
Situation
Background
Assessment
Recommendation
Gauze |- |correct |answer |loose |weave |very |absorbent
Telfa |- |correct |answer |nonstick |less |absorbent
ABD |- |correct |answer |thick |and |very |absorbent, |usually |outer |dressing |material
hydrocolloid |dressing |- |correct |answer |opaque, |non-breathable |dressing
occlusive |- |correct |answer |hydrocolloid |is |a |type |of |occlusive |(adhesive |around |absorbent |
dressing, |non-breathable |- |used |to |keep |drainage |and |air |on |absorbent |pad |or |air |from |
entering |wound |area)
Purpose |of |dressing |- |correct |answer |protection |and |coverage |of |impaired |skin |integrity |and |
impaired |tissue |integrity
assessment |pre-dressing |change |- |correct |answer |pain |assess, |what |type |of |dressing, |type |& |
amount |of |drainage, |wound |assess, |periwound, |skill |performed, |type |pf |dressing |applied, |
tolerance |of |procedure, |record |& |report |any |variance
, assessments |post |dressing |change |- |correct |answer |dressing |integrity, |& |tolerance |of |
procedure, |pain |assessment
To |determine |C |& |S |of |wound |- |correct |answer |clean |wound |before |culture |taken, |clean |to |
dirty, |swirl |never |swab |back |and |forth, |use |different |swabs |for |undermining |or |tunneling, |label
|and |record, |report |any |variance
steps |to |clean |incisions |- |correct |answer |always |clean |simple |wound |first, |then |farthest |from |
you, |then |closest. |wet |then |dry |repeat
steps |to |cleanse |drains |- |correct |answer |clean |incision |first |and |always |cleanse |drain |away |
from |incision
purpose |of |drains |- |correct |answer |remove |& |decrease |fluids |(blood, |lymph |and |other |fluids) |
and |allow |the |body |to |heal |quicker
what |does |a |nurse |need |to |do |before |discontinuing |a |drain |- |correct |answer |cleanse |peri-
wound, |drain |drainage |(make |sure |to |decompress)
purpose |of |packing |a |complex |wound |- |correct |answer |absorb |drainage, |keep |moist |and |
prevent |edges |from |closing |(leaving |areas |to |develop |infection)
stage |1 |pressure |ulcer |- |correct |answer |non-banchable |erythema |of |intact |sin
stage |2 |pressure |ucler |- |correct |answer |partial |thickness |skin |loss |involving |epidermis, |dermis |
or |both
stage |3 |pressure |ulcer |- |correct |answer |full |thickness |skin |loss |involving |damage |to |or |necrosis |
of |SC |tissue |that |may |extend |to |but |not |through |the |underlying |fascia
stage |4 |pressure |ulcer |- |correct |answer |full |thickness |skin |loss |with |extensive |destruction, |
tissue |necrosis, |or |damage |to |muscle, |bone, |or |supporting |structures
| | | | | |
correct answers |
SBAR |- |correct |answer |Its |a |framework
Situation
Background
Assessment
Recommendation
Gauze |- |correct |answer |loose |weave |very |absorbent
Telfa |- |correct |answer |nonstick |less |absorbent
ABD |- |correct |answer |thick |and |very |absorbent, |usually |outer |dressing |material
hydrocolloid |dressing |- |correct |answer |opaque, |non-breathable |dressing
occlusive |- |correct |answer |hydrocolloid |is |a |type |of |occlusive |(adhesive |around |absorbent |
dressing, |non-breathable |- |used |to |keep |drainage |and |air |on |absorbent |pad |or |air |from |
entering |wound |area)
Purpose |of |dressing |- |correct |answer |protection |and |coverage |of |impaired |skin |integrity |and |
impaired |tissue |integrity
assessment |pre-dressing |change |- |correct |answer |pain |assess, |what |type |of |dressing, |type |& |
amount |of |drainage, |wound |assess, |periwound, |skill |performed, |type |pf |dressing |applied, |
tolerance |of |procedure, |record |& |report |any |variance
, assessments |post |dressing |change |- |correct |answer |dressing |integrity, |& |tolerance |of |
procedure, |pain |assessment
To |determine |C |& |S |of |wound |- |correct |answer |clean |wound |before |culture |taken, |clean |to |
dirty, |swirl |never |swab |back |and |forth, |use |different |swabs |for |undermining |or |tunneling, |label
|and |record, |report |any |variance
steps |to |clean |incisions |- |correct |answer |always |clean |simple |wound |first, |then |farthest |from |
you, |then |closest. |wet |then |dry |repeat
steps |to |cleanse |drains |- |correct |answer |clean |incision |first |and |always |cleanse |drain |away |
from |incision
purpose |of |drains |- |correct |answer |remove |& |decrease |fluids |(blood, |lymph |and |other |fluids) |
and |allow |the |body |to |heal |quicker
what |does |a |nurse |need |to |do |before |discontinuing |a |drain |- |correct |answer |cleanse |peri-
wound, |drain |drainage |(make |sure |to |decompress)
purpose |of |packing |a |complex |wound |- |correct |answer |absorb |drainage, |keep |moist |and |
prevent |edges |from |closing |(leaving |areas |to |develop |infection)
stage |1 |pressure |ulcer |- |correct |answer |non-banchable |erythema |of |intact |sin
stage |2 |pressure |ucler |- |correct |answer |partial |thickness |skin |loss |involving |epidermis, |dermis |
or |both
stage |3 |pressure |ulcer |- |correct |answer |full |thickness |skin |loss |involving |damage |to |or |necrosis |
of |SC |tissue |that |may |extend |to |but |not |through |the |underlying |fascia
stage |4 |pressure |ulcer |- |correct |answer |full |thickness |skin |loss |with |extensive |destruction, |
tissue |necrosis, |or |damage |to |muscle, |bone, |or |supporting |structures
