Exam 3 nur 155 Questions with 100% Correct
Answers
Laceration Correct Answer: Tissue torn apart often by
accidents
Abrasion Correct Answer: Surface scrape either
unintentional or intentional
Contusion Correct Answer: Blow from a blunt instrument
Avulsion Correct Answer: A wound that occurs when
tissue is separated from the body
Penetrating wound Correct Answer: Penetration of the
skin and underlying tissue
Skin tear Correct Answer: a break or rip in the outer
layers of the skin; the epidermis separates from the
underlying tissues
Labs associated with wounds Correct Answer: WBC >
hEMOGLOBIN < (O2 TO TISSUE)
SERUM PROTEIN (CONTAIN ALBUMIN)
,WOUND CULTURE: PT, PTT, INR, PLATELET.
Normal lab value Correct Answer: WBC 5-10
hemoglobin: male 14-18, female 12-16
Albumin: 3.5-5
PTT: 20-30 SEC
PT: 11-12.5 SEC
INR: 0.9-1.2 SEC
PLT: 150-400
STATE THE FOUR STAGES OF PRESSURE ULCER Correct
Answer: Stage 1: nonblanchable errythema, no
ulceration
stage 2: partial thickness, skin loss abrasion involving
epidermis and dermis
stage 3: full thickness skin loss involving damage or
necrosis of subcutaneous tissue that may extend down
to but not through underline fascia
, stage 4: full thickness skin loss with tissue necrosis with
damage to muscle and bone
Braden scale Correct Answer: A tool for predicting
pressure ulcer risk
total 23 points, < 18 at risk
Norton pressure area risk assesment Correct Answer:
Total score 24, 15-16 considered indicators not predictors
at risk
RYB- RED Correct Answer: regeneration phase- gentle
cleansing don't apply pressure protect agranulation
tissue
use non-cytotoxic wound cleanser w/o pressure
alcohol free barrier film
PROTECT-COVER
RYB- BLACK Correct Answer: DEBRIDE (REMOVAL OF
NECROTIC MATERIAL)
RYB- YELLOW Correct Answer: CLEANSE
Answers
Laceration Correct Answer: Tissue torn apart often by
accidents
Abrasion Correct Answer: Surface scrape either
unintentional or intentional
Contusion Correct Answer: Blow from a blunt instrument
Avulsion Correct Answer: A wound that occurs when
tissue is separated from the body
Penetrating wound Correct Answer: Penetration of the
skin and underlying tissue
Skin tear Correct Answer: a break or rip in the outer
layers of the skin; the epidermis separates from the
underlying tissues
Labs associated with wounds Correct Answer: WBC >
hEMOGLOBIN < (O2 TO TISSUE)
SERUM PROTEIN (CONTAIN ALBUMIN)
,WOUND CULTURE: PT, PTT, INR, PLATELET.
Normal lab value Correct Answer: WBC 5-10
hemoglobin: male 14-18, female 12-16
Albumin: 3.5-5
PTT: 20-30 SEC
PT: 11-12.5 SEC
INR: 0.9-1.2 SEC
PLT: 150-400
STATE THE FOUR STAGES OF PRESSURE ULCER Correct
Answer: Stage 1: nonblanchable errythema, no
ulceration
stage 2: partial thickness, skin loss abrasion involving
epidermis and dermis
stage 3: full thickness skin loss involving damage or
necrosis of subcutaneous tissue that may extend down
to but not through underline fascia
, stage 4: full thickness skin loss with tissue necrosis with
damage to muscle and bone
Braden scale Correct Answer: A tool for predicting
pressure ulcer risk
total 23 points, < 18 at risk
Norton pressure area risk assesment Correct Answer:
Total score 24, 15-16 considered indicators not predictors
at risk
RYB- RED Correct Answer: regeneration phase- gentle
cleansing don't apply pressure protect agranulation
tissue
use non-cytotoxic wound cleanser w/o pressure
alcohol free barrier film
PROTECT-COVER
RYB- BLACK Correct Answer: DEBRIDE (REMOVAL OF
NECROTIC MATERIAL)
RYB- YELLOW Correct Answer: CLEANSE
