NURS 6011 Study Guide for Exam 3
Questions and Correct Answers/ Latest
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normal BP
Ans: 120/80
normal respiratory rate
Ans: 12-20
normal pulse rate
Ans: 60-100
Normal temperature
Ans: 97.8-99.1
debridement
Ans: cleaning away devitalized tissue and foreign matter from
a wound
dehiscence
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Ans: separation of layers of a surgical wound; may be partial,
superficial or a complete disruption of the surgical wound
desiccation
Ans: dehydration
the process of being rendered free from moisture
epithelialization
Ans: 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
Ans: thick, leathery, scar or dry crust that is necrotic and must
be removed for adequate healing to occur
evisceration
Ans: protrusion of viscera through an incision
purulent drainage
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Ans: compromised of WBCs, liquefied dead tissue debris, and
both dead and live bacteria
an intentional wound is the result of?
Ans: 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
Ans: 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
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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?
Ans: 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?
Ans: 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?
Ans: 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
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