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NURS 221 - Final Exam Questions with
Detailed Verified Answers
What is wound dehiscence?
⼀Answer:⼀ A partial or total rupture (separation) of a sutured
wound, usually with separation of underlying skin layers
What is a partial or total rupture (separation) of a sutured wound,
usually with separation of underlying skin layers called?
⼀Answer:⼀ Dehiscence
What is wound evisceration?
⼀Answer:⼀ A dehiscence that involves the protrusion of visceral
organs through a wound opening
What is a dehiscence that involves the protrusion of visceral
organs through a wound opening called?
⼀Answer:⼀ Evisceration
What are manifestations of wound dehiscence?
⼀Answer:⼀ Significant increase in the flow of serosanguineous fluid
on the wound dressings, immediate history of sudden straining, client
reporting a "popping" sensation or "giving way" in the area,
visualization of viscera
How can dehiscence/evisceration be prevented?
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⼀Answer:⼀ Thin, folded blanket or small pillow over surgical wounds
when client coughs in order to support the wound
What are immediate nursing interventions for wound dehiscence?
⼀Answer:⼀ Call for help, cover wound with sterile towels or
dressings soaked with sterile normal saline, position client supine with
hips and knees bent, observe for indications of shock, keep the client
NPO
How soon after surgery does infection most commonly occur?
⼀Answer:⼀ 3-11 days
What are manifestations of surgical infection?
⼀Answer:⼀ Purulent drainage, pain, redness, edema, fever, chills,
odor, increase in HR and RR, increase in WBC count
What are the causes of pressure ulcers?
⼀Answer:⼀ Inhibited blood flow r/t immobility, incontinence,
friction/shearing, inadequate nutrition/hydration, vascular problems
Describe a stage 1 pressure ulcer
⼀Answer:⼀ Non-blanchable erythema
Describe a stage 2 pressure ulcer
⼀Answer:⼀ Partial thickness, involves epidermis and dermis; can
appear as an abrasion, blister, or shallow crater; may be scant
drainage
Which pressure ulcer stage involves partial thickness loss?
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⼀Answer:⼀ 2
Which pressure ulcer stage can appear as an abrasion, blister, or
shallow crater?
⼀Answer:⼀ 2
Describe a stage 3 pressure ulcer
⼀Answer:⼀ Full-thickness skin loss, appears as a deep crater without
showing muscle or bone; drainage and infection are common
Describe a stage 4 pressure ulcer
⼀Answer:⼀ Full-thickness tissue loss, damage to muscle, bone, or
supporting structures; can be sinus tracts, deep pockets of infection,
tunneling, undermining, eschar, slough
Which scale measures the risk for pressure ulcers?
⼀Answer:⼀ Braden scale
How can a nurse help to prevent pressure ulcers?
⼀Answer:⼀ Keep skin dry and clean, wrinkle-free sheet, reposition
every 2 hours in bed and every one hour in chair, head at most 30
degrees, raise heels, ambulate as much as possible, shift weight every
15 minutes if mobile, minimize friction, use barriers and pressure-
reducing devices, do not massage bony prominences, ensure serum
albumin is 3.5 or higher; provide vitamin A, C, copper, and zinc
How often should a patient be re-positioned?
⼀Answer:⼀ Every 2 hours in bed, 1 hour in chair
NURS 221 - Final Exam Questions with
Detailed Verified Answers
What is wound dehiscence?
⼀Answer:⼀ A partial or total rupture (separation) of a sutured
wound, usually with separation of underlying skin layers
What is a partial or total rupture (separation) of a sutured wound,
usually with separation of underlying skin layers called?
⼀Answer:⼀ Dehiscence
What is wound evisceration?
⼀Answer:⼀ A dehiscence that involves the protrusion of visceral
organs through a wound opening
What is a dehiscence that involves the protrusion of visceral
organs through a wound opening called?
⼀Answer:⼀ Evisceration
What are manifestations of wound dehiscence?
⼀Answer:⼀ Significant increase in the flow of serosanguineous fluid
on the wound dressings, immediate history of sudden straining, client
reporting a "popping" sensation or "giving way" in the area,
visualization of viscera
How can dehiscence/evisceration be prevented?
, Page | 2
⼀Answer:⼀ Thin, folded blanket or small pillow over surgical wounds
when client coughs in order to support the wound
What are immediate nursing interventions for wound dehiscence?
⼀Answer:⼀ Call for help, cover wound with sterile towels or
dressings soaked with sterile normal saline, position client supine with
hips and knees bent, observe for indications of shock, keep the client
NPO
How soon after surgery does infection most commonly occur?
⼀Answer:⼀ 3-11 days
What are manifestations of surgical infection?
⼀Answer:⼀ Purulent drainage, pain, redness, edema, fever, chills,
odor, increase in HR and RR, increase in WBC count
What are the causes of pressure ulcers?
⼀Answer:⼀ Inhibited blood flow r/t immobility, incontinence,
friction/shearing, inadequate nutrition/hydration, vascular problems
Describe a stage 1 pressure ulcer
⼀Answer:⼀ Non-blanchable erythema
Describe a stage 2 pressure ulcer
⼀Answer:⼀ Partial thickness, involves epidermis and dermis; can
appear as an abrasion, blister, or shallow crater; may be scant
drainage
Which pressure ulcer stage involves partial thickness loss?
, Page | 3
⼀Answer:⼀ 2
Which pressure ulcer stage can appear as an abrasion, blister, or
shallow crater?
⼀Answer:⼀ 2
Describe a stage 3 pressure ulcer
⼀Answer:⼀ Full-thickness skin loss, appears as a deep crater without
showing muscle or bone; drainage and infection are common
Describe a stage 4 pressure ulcer
⼀Answer:⼀ Full-thickness tissue loss, damage to muscle, bone, or
supporting structures; can be sinus tracts, deep pockets of infection,
tunneling, undermining, eschar, slough
Which scale measures the risk for pressure ulcers?
⼀Answer:⼀ Braden scale
How can a nurse help to prevent pressure ulcers?
⼀Answer:⼀ Keep skin dry and clean, wrinkle-free sheet, reposition
every 2 hours in bed and every one hour in chair, head at most 30
degrees, raise heels, ambulate as much as possible, shift weight every
15 minutes if mobile, minimize friction, use barriers and pressure-
reducing devices, do not massage bony prominences, ensure serum
albumin is 3.5 or higher; provide vitamin A, C, copper, and zinc
How often should a patient be re-positioned?
⼀Answer:⼀ Every 2 hours in bed, 1 hour in chair
