EXAM 2: NSG300 / NSG 300 (LATEST 2025 UPDATES
STUDY BUNDLE WITH COMPLETE SOLUTIONS)
FOUNDATIONS OF NURSING EXAM | QUESTIONS
AND VERIFIED ANSWERS | 100% CORRECT | GRADE
A - GCU
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
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-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
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-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
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.
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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