NR 224 Fundamentals Exam 2 UPDATED ACTUAL Questions and CORRECT Answers

NR 224 Fundamentals Exam 2 UPDATED
ACTUAL Questions and CORRECT
Answers
Acute wounds - CORRECT ANSWER - trauma and surgical



Chronic - CORRECT ANSWER - vascular compromise



Pressure Ulcers - CORRECT ANSWER - Impaired skin integrity r/t unrelieved ,
prolonged pressure in combination with shear or friction. (bed sores)


At risk pressure ulcer pt... - CORRECT ANSWER - Impaired sensory
Spinal cord injuries
Immobile patients
Shear/Friction
Moisture
Altered level of consciousness


Stage 1 pressure ulcer - CORRECT ANSWER - - Nonblanchable erythema
-Skin remains intact
Nursing Dx: (Ineffective tissue perfusion)


Stage II Pressure Ulcer - CORRECT ANSWER - - open skin wound
- shallow
- red/pink color


Stage III Pressure Ulcer - CORRECT ANSWER - - full thickness tissue loss
- subcutaneous fat visible

, Stage IV Pressure Ulcer - CORRECT ANSWER - - exposed bone, muscle or tendon
- tunneling and undermining needed


Unstageable Pressure Ulcer - CORRECT ANSWER - - completely covered in slough
- some of wound can be necrotic
- difficult to stage
- after deprevement stage can be determined


Suspected Deep Tissue Ulcer - CORRECT ANSWER - purple localized area of discolored
intact skin blood filled blister.
-mushy
- warm or cool


Pressure Ulcer Assessment and documentation - CORRECT ANSWER - Location
Wound Bed
-Tunneling
-Undermining
-Granulation tissue
-Slough
-Eschar
Drainage
Odor
Size
LxW
Depth
Pain
Dressing change