Nursing II Wound Ostomy and Continence
test 4 Questions With Complete Solutions
5 lessons you can apply to wound care Correct
Answers Avoid second guessing wound sizes
Be prepared
Invoke the buddy system
Adequate nutrition is a very important part of
healing
Don't trust old wise tales
Abrasion and Laceration Correct Answers An
Abrasion or "excoriation" is a wearing away of the
upper layer of skin in result of applied friction
force. Laceration is an open area
Types of approximation (stitches)
Interrupted
Running
Subcuticular
Best practice for PREVENTION of medical devices-
related pressure ulcers Correct Answers Choose
Cushion
Remove
Avoid
Educate
Be aware
Confirm
,Braden Q scale risk score Correct Answers Mild
risk - 22-25
Moderate risk - 17-21
High risk- <16
Braden Scale Correct Answers The Braden scale
score is the total of 6 subscales
Sensory Perception (1-4)
Moisture (1-4)
Activity (1-4)
Mobility (1-4)
Nutrition (1-4)
Friction and Shear (1-3)
Total scores range 6-23
Braden Scale Scoring Correct Answers Let the sub
score guide you to the most effective intervention
Place interventions on care place
Document response to interventions
Can friction ulcers be reversed? Correct Answers
Yes they can be easily reversed, unless the cause
is not removed and they are generally superficial
CFCN nurses have elevated the quality of care for
patients in? Correct Answers Hospitals
Long-term care facilities
Podiatry offices
Patient's own home
, Common conditions often misconstrued as
pressure ulcers include: Correct Answers Skin
tears
Arterial Ulcers
Diabetic Ulcers
Venous Ulcers
Perineal Dermatitis
Friction
Maceration (pruning)
Shear
Document the color of wound base Correct
Answers Pale pink, pink, red (granulating tissue),
yellow, green, black
Describe the percentage of tissue present - 75%
black and 25% red
Examples of shear and friction? Correct Answers
Pulling patient up in bed
Patient is fowler's position who slides down in bed
sliding patient from bed to stretcher
Heels and elbows which aid in movement for
bedridden patients
Agitated patients or those experiencing seizures
superficial abrasion or blistering
Examples of skin damage from moisture Correct
Answers fecal and urinary incontinence
Wound drainage
Respiratory secretions (tracheostomy site)
test 4 Questions With Complete Solutions
5 lessons you can apply to wound care Correct
Answers Avoid second guessing wound sizes
Be prepared
Invoke the buddy system
Adequate nutrition is a very important part of
healing
Don't trust old wise tales
Abrasion and Laceration Correct Answers An
Abrasion or "excoriation" is a wearing away of the
upper layer of skin in result of applied friction
force. Laceration is an open area
Types of approximation (stitches)
Interrupted
Running
Subcuticular
Best practice for PREVENTION of medical devices-
related pressure ulcers Correct Answers Choose
Cushion
Remove
Avoid
Educate
Be aware
Confirm
,Braden Q scale risk score Correct Answers Mild
risk - 22-25
Moderate risk - 17-21
High risk- <16
Braden Scale Correct Answers The Braden scale
score is the total of 6 subscales
Sensory Perception (1-4)
Moisture (1-4)
Activity (1-4)
Mobility (1-4)
Nutrition (1-4)
Friction and Shear (1-3)
Total scores range 6-23
Braden Scale Scoring Correct Answers Let the sub
score guide you to the most effective intervention
Place interventions on care place
Document response to interventions
Can friction ulcers be reversed? Correct Answers
Yes they can be easily reversed, unless the cause
is not removed and they are generally superficial
CFCN nurses have elevated the quality of care for
patients in? Correct Answers Hospitals
Long-term care facilities
Podiatry offices
Patient's own home
, Common conditions often misconstrued as
pressure ulcers include: Correct Answers Skin
tears
Arterial Ulcers
Diabetic Ulcers
Venous Ulcers
Perineal Dermatitis
Friction
Maceration (pruning)
Shear
Document the color of wound base Correct
Answers Pale pink, pink, red (granulating tissue),
yellow, green, black
Describe the percentage of tissue present - 75%
black and 25% red
Examples of shear and friction? Correct Answers
Pulling patient up in bed
Patient is fowler's position who slides down in bed
sliding patient from bed to stretcher
Heels and elbows which aid in movement for
bedridden patients
Agitated patients or those experiencing seizures
superficial abrasion or blistering
Examples of skin damage from moisture Correct
Answers fecal and urinary incontinence
Wound drainage
Respiratory secretions (tracheostomy site)
