D439 FOUNDATIONS OF NURSING EXAM
QUESTIONS AND CORRECT ANSWERS!!
What are things to promote sleep?
-Routine sleep schedule,
-PM should involve a cool/dark room, reduce any stimuli in the bedroom, and no naps in the
afternoon; if they do, limit to 20 mins per day.
-AM should involve a sunny/bright room,
-Do not turn off alarms in pts room
-Do not increase sedation at night
-Replicate your pts sleep schedule
-Avoid these 4-6hrs before bed: caffeine, chocolate (any form), soda, tea, alcohol, nicotine,
exercise, going to bed hungry or too full.
What is the minimum time one should wash their hands?
15 seconds
How would you take care of a wound?
Follow your hospital's recommendations. Debridement if needed, keep moist, clean, monitor for
signs of infection.
What occurs in a pressure wound stage one?
Intact skin with persistent, nonblanchable redness that can feel warmer or cooler than the
adjacent tissue.
What occurs in a pressure wound stage two?
Involves the epidermis and the dermis. The wound bed is viable with a reddish-pinkish bed
without slough, eschar, granulation tissue, or adipose tissue. It can appear as an intact or ruptured
blister.
What occurs in a pressure wound stage three?
, Visible adipose tissue with possible granulation tissue and wound edges appear rolled under;
some slough, eschar present. Affects the epidermis, dermis, and subcutaneous tissue.
What occurs in a pressure wound stage four?
Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or tendon exposed in the
wound or easily palpable.
What occurs in a pressure wound that is unstageable?
Eschar and slough make it impossible to see. Perform debridement.
What occurs when the pressure wound is at the deep tissue?
Intact skin is nonblanchable with deep red, maroon, or purple discoloration; open wounds have a
dark wound bed or blood blister. Pain and temperature changes can be detected earlier than color
changes. Occurs most frequently over the heels, ankles, ischial tuberosities, and sacral area.
During the healing process of a wound, what occurs during the primary intention stage?
-Little or no tissue loss
-Heals rapidly, low risk for infection, and no/minimal scarring
-Ex. closed surgical incision with staples, sutures, or liquid glue to seal laceration
During the healing process of a wound, what occurs during the secondary intention stage?
-Loss of tissue
-Longer healing time, increased risk for infection, scarring, and is healed by granulation
-Ex. pressure injury left open to heal
During the healing process of a wound, what occurs during the tertiary intention stage?
-Tissue is deep and is widely separated
-Spontaneous opening of a previously closed wound; closure of these wounds occurs when they
are free of infection and edema
-Long healing time, risk of infection, extensive drainage and tissue debris
-Ex. abdominal wound initially left open until infection is resolved and then closed
What is serous drainage from a wound?
QUESTIONS AND CORRECT ANSWERS!!
What are things to promote sleep?
-Routine sleep schedule,
-PM should involve a cool/dark room, reduce any stimuli in the bedroom, and no naps in the
afternoon; if they do, limit to 20 mins per day.
-AM should involve a sunny/bright room,
-Do not turn off alarms in pts room
-Do not increase sedation at night
-Replicate your pts sleep schedule
-Avoid these 4-6hrs before bed: caffeine, chocolate (any form), soda, tea, alcohol, nicotine,
exercise, going to bed hungry or too full.
What is the minimum time one should wash their hands?
15 seconds
How would you take care of a wound?
Follow your hospital's recommendations. Debridement if needed, keep moist, clean, monitor for
signs of infection.
What occurs in a pressure wound stage one?
Intact skin with persistent, nonblanchable redness that can feel warmer or cooler than the
adjacent tissue.
What occurs in a pressure wound stage two?
Involves the epidermis and the dermis. The wound bed is viable with a reddish-pinkish bed
without slough, eschar, granulation tissue, or adipose tissue. It can appear as an intact or ruptured
blister.
What occurs in a pressure wound stage three?
, Visible adipose tissue with possible granulation tissue and wound edges appear rolled under;
some slough, eschar present. Affects the epidermis, dermis, and subcutaneous tissue.
What occurs in a pressure wound stage four?
Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or tendon exposed in the
wound or easily palpable.
What occurs in a pressure wound that is unstageable?
Eschar and slough make it impossible to see. Perform debridement.
What occurs when the pressure wound is at the deep tissue?
Intact skin is nonblanchable with deep red, maroon, or purple discoloration; open wounds have a
dark wound bed or blood blister. Pain and temperature changes can be detected earlier than color
changes. Occurs most frequently over the heels, ankles, ischial tuberosities, and sacral area.
During the healing process of a wound, what occurs during the primary intention stage?
-Little or no tissue loss
-Heals rapidly, low risk for infection, and no/minimal scarring
-Ex. closed surgical incision with staples, sutures, or liquid glue to seal laceration
During the healing process of a wound, what occurs during the secondary intention stage?
-Loss of tissue
-Longer healing time, increased risk for infection, scarring, and is healed by granulation
-Ex. pressure injury left open to heal
During the healing process of a wound, what occurs during the tertiary intention stage?
-Tissue is deep and is widely separated
-Spontaneous opening of a previously closed wound; closure of these wounds occurs when they
are free of infection and edema
-Long healing time, risk of infection, extensive drainage and tissue debris
-Ex. abdominal wound initially left open until infection is resolved and then closed
What is serous drainage from a wound?
