NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
what places patients at risk for pressure ulcers/impaired skin integrity - (ANSWER)pressure intensity,
pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC,
shear, friction, moisture
layers of the skin - (ANSWER)epidermis, dermis (collagen)
body's defenses against infection - (ANSWER)normal flora, inflammatory response, immune response
comprehensive wound assessment - (ANSWER)-ongoing assessment from time of injury, wound care,
any condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description, response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - (ANSWER)assesses risk for developing pressure ulcers; includes patient's sensory
perception, moisture, activity, mobility, nutrition, friction and shear; the lower the number the higher
the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
type 1 ulcers - (ANSWER)skin is intact but may be red or pink and warm to the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - (ANSWER)partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers - (ANSWER)full-thickness tissue loss with visible fat (subcutaneous layer); pale-yellow color;
may include slough but does not obstruct view of depth of injury
,NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
type 4 ulcers - (ANSWER)full-thickness tissue loss with exposed bone, muscle, or tendon. possible
tunneling and undermining
unstageable pressure ulcer - (ANSWER)base of ulcer covered by slough and/or eschar in the wound bed
so the depth is unknown; exudate;
deep tissue injury - (ANSWER)Purple or maroon localized area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/or shear.
how should you clean a wound - (ANSWER)from least to most contaminated
eschar - (ANSWER)black, brown or necrotic tissue in wound bed; needs to be removed before healing
slough - (ANSWER)stringy pale-yellowish tissue that lays in the wound bed; needs to be removed before
healing
if a patient has slough, eschar, and infectious exudate which one would you be most concerned about -
(ANSWER)infectious exudate
factors influencing heat and cold tolerance - (ANSWER)Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - (ANSWER)location, staging (depth), type and % of tissue in
wound bed, wound dimensions (including tunneling), exudate description (if odor is present), and
condition of surrounding skin
why is depth of an ulcer important - (ANSWER)because the wound heals inside-out
,NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
granulation tissue - (ANSWER)good, fresh tissue that forms during the healing of a wound (wound bed
will be red, moist, and shiny)
How does a partial thickness wound heal? - (ANSWER)by regeneration (scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate. 1st 24hrs after
wounding.
-epithelial proliferation (reproduction): starts at wound edges and epidermal cells lining appendages
(quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry wound, the cells move
down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and appear as dry, pink
tissue
How does a full thickness wound heal? - (ANSWER)by forming new tissue/scar formation, which takes
longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of surrounding capillaries
and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is filled with replacement
tissue (collagen, contraction, and granulation tissue), and the surface is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for several months. Collagen
fibers undergo remodeling or reorganization before assuming their normal appearance
primary intention - (ANSWER)wound that is closed/approximated; little tissue loss; low risk of infection;
quick healing with no scar usually (surgical incision)
secondary intention - (ANSWER)a wound with loss of tissue; wound is not approximated; have to heal
from the inside-out; if scarring is severe, loss of tissue function may be permanent (pressure ulcers,
surgical wound that has tissue loss)
, NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
tertiary intention - (ANSWER)Wound that is left open for several days, then wound edges are
approximated; doctor can monitor status of wound
complications of wound healing - (ANSWER)hemorrhage, infection, dehiscence, evisceration
CMS - (ANSWER)created policy for hospitals to no longer receive additional reimbursement for care
related to eight conditions to improve quality of health care
signs and symptoms of wound infection - (ANSWER)Contaminated or traumatic wounds: 2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
Dehiscence
Evisceration
what is needed for wound healing - (ANSWER)protein (albumin)
factors influencing pressure ulcer formation and wound healing - (ANSWER)-nutrition
-tissue perfusion
-infection
-age
-psychosocial impacts (body image)
when should you give an analgesic - (ANSWER)at least 30 minutes before removing a wound dressing
Scientific Method nursing - (ANSWER)•identify the problem,
what places patients at risk for pressure ulcers/impaired skin integrity - (ANSWER)pressure intensity,
pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC,
shear, friction, moisture
layers of the skin - (ANSWER)epidermis, dermis (collagen)
body's defenses against infection - (ANSWER)normal flora, inflammatory response, immune response
comprehensive wound assessment - (ANSWER)-ongoing assessment from time of injury, wound care,
any condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description, response to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - (ANSWER)assesses risk for developing pressure ulcers; includes patient's sensory
perception, moisture, activity, mobility, nutrition, friction and shear; the lower the number the higher
the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
type 1 ulcers - (ANSWER)skin is intact but may be red or pink and warm to the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - (ANSWER)partial-thickness loss of dermis; shallow broken skin; red-pink wound bed
type 3 ulcers - (ANSWER)full-thickness tissue loss with visible fat (subcutaneous layer); pale-yellow color;
may include slough but does not obstruct view of depth of injury
,NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
type 4 ulcers - (ANSWER)full-thickness tissue loss with exposed bone, muscle, or tendon. possible
tunneling and undermining
unstageable pressure ulcer - (ANSWER)base of ulcer covered by slough and/or eschar in the wound bed
so the depth is unknown; exudate;
deep tissue injury - (ANSWER)Purple or maroon localized area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/or shear.
how should you clean a wound - (ANSWER)from least to most contaminated
eschar - (ANSWER)black, brown or necrotic tissue in wound bed; needs to be removed before healing
slough - (ANSWER)stringy pale-yellowish tissue that lays in the wound bed; needs to be removed before
healing
if a patient has slough, eschar, and infectious exudate which one would you be most concerned about -
(ANSWER)infectious exudate
factors influencing heat and cold tolerance - (ANSWER)Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - (ANSWER)location, staging (depth), type and % of tissue in
wound bed, wound dimensions (including tunneling), exudate description (if odor is present), and
condition of surrounding skin
why is depth of an ulcer important - (ANSWER)because the wound heals inside-out
,NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
granulation tissue - (ANSWER)good, fresh tissue that forms during the healing of a wound (wound bed
will be red, moist, and shiny)
How does a partial thickness wound heal? - (ANSWER)by regeneration (scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate. 1st 24hrs after
wounding.
-epithelial proliferation (reproduction): starts at wound edges and epidermal cells lining appendages
(quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry wound, the cells move
down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and appear as dry, pink
tissue
How does a full thickness wound heal? - (ANSWER)by forming new tissue/scar formation, which takes
longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of surrounding capillaries
and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is filled with replacement
tissue (collagen, contraction, and granulation tissue), and the surface is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for several months. Collagen
fibers undergo remodeling or reorganization before assuming their normal appearance
primary intention - (ANSWER)wound that is closed/approximated; little tissue loss; low risk of infection;
quick healing with no scar usually (surgical incision)
secondary intention - (ANSWER)a wound with loss of tissue; wound is not approximated; have to heal
from the inside-out; if scarring is severe, loss of tissue function may be permanent (pressure ulcers,
surgical wound that has tissue loss)
, NSG-300 EXAM 2 (TOPICS 4-6) QUESTIONS AND ANSWERS
tertiary intention - (ANSWER)Wound that is left open for several days, then wound edges are
approximated; doctor can monitor status of wound
complications of wound healing - (ANSWER)hemorrhage, infection, dehiscence, evisceration
CMS - (ANSWER)created policy for hospitals to no longer receive additional reimbursement for care
related to eight conditions to improve quality of health care
signs and symptoms of wound infection - (ANSWER)Contaminated or traumatic wounds: 2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
Dehiscence
Evisceration
what is needed for wound healing - (ANSWER)protein (albumin)
factors influencing pressure ulcer formation and wound healing - (ANSWER)-nutrition
-tissue perfusion
-infection
-age
-psychosocial impacts (body image)
when should you give an analgesic - (ANSWER)at least 30 minutes before removing a wound dressing
Scientific Method nursing - (ANSWER)•identify the problem,
