NSE 211 Final Exam Questions And
Answers Verified 100% Correct
risk factors for PI development - ANSWER -- impaired sensory perception
- alterations in LOC
- impaired mobility
- shear
- nutrition
- tissue perfusion
- infection
- pain
- friction
- moisture
- age
- psychological impact of wounds
What are nursing interventions for a decreased sensory perception? - ANSWER --
Assess pressure points for signs of nonblanching reactive hyperemia
- Provide a pressure-redistribution surface
What are nursing interventions for moisture? - ANSWER -- Assess need for
incontinence management
- After e/c incontinent episode, cleanse area w/ no-rinse perineal cleanser & protect
skin w/ moisture-barrier ointment
What are nursing interventions for friction & shear? - ANSWER -- Reposition
patient by using a drawsheet to lift the patient off the surface
- Ensure heels are supported
- provide trapeze to facilitate movement
- position patient @ 30 degree lateral turn & limit head elevation to 30 degrees
, nursing interventions for decreased activity or mobility - ANSWER -- establish &
post an individualized turning schedule
- ensure functionality of pressure off-loading devices for wheelchair, bed
nursing interventions for poor nutrition - ANSWER -- assess teeth or dentures;
ensure good mouth care
- provide adequate nutritional fluid intake; assist w/ intake as necessary
- consult dietitian for nutritional evaluation
S&S of suspected deep tissue injury - ANSWER -- localized area of persistent
nonblanchable deep red, maroon, purple discolourationm revealing dark wound
bed or blood-filled blister.
- pain & temp change often
stage 1 PI - ANSWER -intact skin w/ localized area of nonblanchable erythema.
stage 2 PI - ANSWER -- partial-thickness loss of skin, w/ *exposed dermis*.
- wound bed is viable, pink, or red & moist.
- may present as intact, or ruptured serum-filled blister.
- this stage should *not be used to describe moisture-associated skin damage*
stage 3 PI - ANSWER -- full thickness tissue loss of skin, where *adipose,
granulation tissue & epibole are often present*
- slough, eschar or both may be visible.
- undermining & tunneling may occur.
- *fascia, muscle tendon, ligament, cartilage & bone aren't exposed*.
stage 4 PI - ANSWER -- full thickness skin & tissue loss
- *exposed fascia, muscle tendon, ligament, cartilage or bone in the ulcer*.
- slough, eschar or both may be seen.
unstageable PI - ANSWER -- full thickness skin & tissue loss in where *tissue
damage within ulcer can't be confirmed* b/c its blocked by slough or eschar.
- if slough/eschar is removed, stage 3 or 4 PI would be seen. Stable eschar should
not be removed however.
, undermining - ANSWER -open area, or tunneling under edge of a wound
Bates Jenson Wound Assessment Tool (BWAT) looks at ... - ANSWER -- location
- size
- depth
- edges
- undermining
- necrotic tissue type & amount
- exudate type & amount
- periwound
- peripheral tissue edema
- peripheral tissue induration
- granulation tissue
- epithelialization
what things do you document about a PI? - ANSWER -- size
- evidence of healing
- characteristics of drainage
- client teaching & pain
how do you evaluate wound healing? - ANSWER -- is wound healing or
becoming chronic?
- what's the dressing effectiveness (adherence, comfort, moisture control)
- psychosocial impact on body image, sexuality, & self concept (smells, scars,
exudates, temp or permanent prosthetics)
What does braden scare evaluate? - ANSWER -- sensory perception
- moisture
- activity lvls
- mobility
- nutrition
- friction & shear
Answers Verified 100% Correct
risk factors for PI development - ANSWER -- impaired sensory perception
- alterations in LOC
- impaired mobility
- shear
- nutrition
- tissue perfusion
- infection
- pain
- friction
- moisture
- age
- psychological impact of wounds
What are nursing interventions for a decreased sensory perception? - ANSWER --
Assess pressure points for signs of nonblanching reactive hyperemia
- Provide a pressure-redistribution surface
What are nursing interventions for moisture? - ANSWER -- Assess need for
incontinence management
- After e/c incontinent episode, cleanse area w/ no-rinse perineal cleanser & protect
skin w/ moisture-barrier ointment
What are nursing interventions for friction & shear? - ANSWER -- Reposition
patient by using a drawsheet to lift the patient off the surface
- Ensure heels are supported
- provide trapeze to facilitate movement
- position patient @ 30 degree lateral turn & limit head elevation to 30 degrees
, nursing interventions for decreased activity or mobility - ANSWER -- establish &
post an individualized turning schedule
- ensure functionality of pressure off-loading devices for wheelchair, bed
nursing interventions for poor nutrition - ANSWER -- assess teeth or dentures;
ensure good mouth care
- provide adequate nutritional fluid intake; assist w/ intake as necessary
- consult dietitian for nutritional evaluation
S&S of suspected deep tissue injury - ANSWER -- localized area of persistent
nonblanchable deep red, maroon, purple discolourationm revealing dark wound
bed or blood-filled blister.
- pain & temp change often
stage 1 PI - ANSWER -intact skin w/ localized area of nonblanchable erythema.
stage 2 PI - ANSWER -- partial-thickness loss of skin, w/ *exposed dermis*.
- wound bed is viable, pink, or red & moist.
- may present as intact, or ruptured serum-filled blister.
- this stage should *not be used to describe moisture-associated skin damage*
stage 3 PI - ANSWER -- full thickness tissue loss of skin, where *adipose,
granulation tissue & epibole are often present*
- slough, eschar or both may be visible.
- undermining & tunneling may occur.
- *fascia, muscle tendon, ligament, cartilage & bone aren't exposed*.
stage 4 PI - ANSWER -- full thickness skin & tissue loss
- *exposed fascia, muscle tendon, ligament, cartilage or bone in the ulcer*.
- slough, eschar or both may be seen.
unstageable PI - ANSWER -- full thickness skin & tissue loss in where *tissue
damage within ulcer can't be confirmed* b/c its blocked by slough or eschar.
- if slough/eschar is removed, stage 3 or 4 PI would be seen. Stable eschar should
not be removed however.
, undermining - ANSWER -open area, or tunneling under edge of a wound
Bates Jenson Wound Assessment Tool (BWAT) looks at ... - ANSWER -- location
- size
- depth
- edges
- undermining
- necrotic tissue type & amount
- exudate type & amount
- periwound
- peripheral tissue edema
- peripheral tissue induration
- granulation tissue
- epithelialization
what things do you document about a PI? - ANSWER -- size
- evidence of healing
- characteristics of drainage
- client teaching & pain
how do you evaluate wound healing? - ANSWER -- is wound healing or
becoming chronic?
- what's the dressing effectiveness (adherence, comfort, moisture control)
- psychosocial impact on body image, sexuality, & self concept (smells, scars,
exudates, temp or permanent prosthetics)
What does braden scare evaluate? - ANSWER -- sensory perception
- moisture
- activity lvls
- mobility
- nutrition
- friction & shear
