NURS 6011 Study Guide for Exam 3 With
Complete Solution
Normal BP - ANSWER 120/80
Normal respiratory rate - ANSWER 12-20
Normal pulse rate - ANSWER 60-100
Normal temperature - ANSWER 97.8-99.1
debridement - ANSWER cleaning away devitalized tissue and foreign matter
from a wound
dehiscence - ANSWER separation of layers of a surgical wound; may be
partial, superficial or a complete disruption of the surgical wound
desiccation - ANSWER dehydration
the process of being rendered free from moisture
epithelialization - ANSWER stage of wound healing in which epithelial cells
form across the surface of a wound; tissue color ranges from the color of
ground glass to pink
eschar - ANSWER thick, leathery, scar or dry crust that is necrotic and must
be removed for adequate healing to occur
evisceration - ANSWER protrusion of viscera through an incision
purulent drainage - ANSWER compromised of WBCs, liquefied dead tissue
debris, and both dead and live bacteria
,an intentional wound is the result of? - ANSWER planned invasive therapy or
treatment
examples are wound resulting from surgery, IV therapy, and lumbar puncture
in older adults what are age related changes that occur that could affect
wound healing - ANSWER skin loses turgor and is more fragile
decreased secretion of enzymes and absorption of nutrients and minerals
may increase risk for delayed wound healing
risk of infection increases because:
-slower inflammatory response
-reduced antibody production and endocrine system function
-increased incidence of chronic illnesses, such as diabetes and CV disease,
that compromise circulation and tissue oxygenation
You have a 6th grader who has been getting bad grades lately, rubs their
eyes frequently, visual acuity is poor what is the nursing diagnosis? -
ANSWER ineffective role performance related to visual impairment
in an older adult the skin loses turgor and is more fragile what are some
nursing interventions to help with that? - ANSWER maintain hydration and IV
fluids as prescribed
maintain record of intake and output
use caution when removing tape
in older adults they experience decreased secretion of enzymes and
absorption of nutrients that increase their risk for delayed wound healing
what are some nursing interventions to combat this? - ANSWER maintain
, intake of adequate calories
ensure that the diet is high in protein, vitamin A, vitamin C and trace
elements
monitor lab results such as serum albumin, total protein
in older adults if they have a wound the risk for infections increases what are
some nursing interventions to combat this? - ANSWER -hand hygiene
-take and record vital signs noting and reporting increased temp
-monitor wound for signs of infection
-administer meds as prescribed
symptoms of infection of a wound include? - ANSWER purulent drainage
increased drainage
pain
redness
swelling in and around the wound
increased body temperature
increased WBC
a pressure injury or ulcer - ANSWER defined as localized damage to the skin
and underlying tissue that usually covers over a bony prominence or is
related to the use of a medical or other device
risk factors for pressure ulcers
AVOID PRESS - ANSWER aging skin
Complete Solution
Normal BP - ANSWER 120/80
Normal respiratory rate - ANSWER 12-20
Normal pulse rate - ANSWER 60-100
Normal temperature - ANSWER 97.8-99.1
debridement - ANSWER cleaning away devitalized tissue and foreign matter
from a wound
dehiscence - ANSWER separation of layers of a surgical wound; may be
partial, superficial or a complete disruption of the surgical wound
desiccation - ANSWER dehydration
the process of being rendered free from moisture
epithelialization - ANSWER stage of wound healing in which epithelial cells
form across the surface of a wound; tissue color ranges from the color of
ground glass to pink
eschar - ANSWER thick, leathery, scar or dry crust that is necrotic and must
be removed for adequate healing to occur
evisceration - ANSWER protrusion of viscera through an incision
purulent drainage - ANSWER compromised of WBCs, liquefied dead tissue
debris, and both dead and live bacteria
,an intentional wound is the result of? - ANSWER planned invasive therapy or
treatment
examples are wound resulting from surgery, IV therapy, and lumbar puncture
in older adults what are age related changes that occur that could affect
wound healing - ANSWER skin loses turgor and is more fragile
decreased secretion of enzymes and absorption of nutrients and minerals
may increase risk for delayed wound healing
risk of infection increases because:
-slower inflammatory response
-reduced antibody production and endocrine system function
-increased incidence of chronic illnesses, such as diabetes and CV disease,
that compromise circulation and tissue oxygenation
You have a 6th grader who has been getting bad grades lately, rubs their
eyes frequently, visual acuity is poor what is the nursing diagnosis? -
ANSWER ineffective role performance related to visual impairment
in an older adult the skin loses turgor and is more fragile what are some
nursing interventions to help with that? - ANSWER maintain hydration and IV
fluids as prescribed
maintain record of intake and output
use caution when removing tape
in older adults they experience decreased secretion of enzymes and
absorption of nutrients that increase their risk for delayed wound healing
what are some nursing interventions to combat this? - ANSWER maintain
, intake of adequate calories
ensure that the diet is high in protein, vitamin A, vitamin C and trace
elements
monitor lab results such as serum albumin, total protein
in older adults if they have a wound the risk for infections increases what are
some nursing interventions to combat this? - ANSWER -hand hygiene
-take and record vital signs noting and reporting increased temp
-monitor wound for signs of infection
-administer meds as prescribed
symptoms of infection of a wound include? - ANSWER purulent drainage
increased drainage
pain
redness
swelling in and around the wound
increased body temperature
increased WBC
a pressure injury or ulcer - ANSWER defined as localized damage to the skin
and underlying tissue that usually covers over a bony prominence or is
related to the use of a medical or other device
risk factors for pressure ulcers
AVOID PRESS - ANSWER aging skin
