Nursing Fundamentals Exam 2 (Galen) Questions With
Complete Solutions
A purulent exudate is best described as: Correct Answer Thick
(due to pus), varied colors (green, blue, or yellow)
A serous exudate is best described as: Correct Answer thin,
watery, colorless exudate; example: fluid in a blister from a burn
Acute Pain NANDA (Wounds) Correct Answer Related to
nerve involvement within the tissue impairment or as a
consequence of procedures used to treat the wound.
Black wounds Correct Answer Are covered by thick necrotic
tissue, or eschar that requires debridement (removal of dead
tissue).
Blood pressure classifications Correct Answer - Normal = 90-
120/60-80
- Prehypertension = 120-139/80-89
- Stage 1 Hypertension = 140-159/90-99
- Stage 2 Hypertension = >160/>100
Braden scale categories Correct Answer sensory perception,
moisture, activity, mobility, nutrition, friction and shear
Can oxygen saturation assessments be delegated? Correct
Answer Yes. However, the RN is responsible for interpretation
of abnormal results.
,Clear absorbent acrylic dressing Correct Answer Description:
transparent absorbent wafer
Purpose: aids in easy wound assessment, protects against
bacteria and shearing, maintains moist wound healing.
Indications: pressure ulcers, skin tears, venous stasis ulcers,
surgical wounds, chemical debridement
Closed wound drainage system Correct Answer -Consists of a
drain connected to either an electric suction or a portable
drainage suction. Examples: hemovac, Jackson-Pratt
-Reduces the potential entry of microorganisms into the wound
through the drain.
Common NANDA diagnosis for skin wounds or risks for skin
breakdown Correct Answer -Risk for Pressure Ulcer
-Risk for Impaired Skin Integrity
-Impaired Skin Integrity
-Impaired Tissue Integrity
Common way heat leaves the body? Correct Answer Radiation
Conduction
Convection
Evaporation
Contraindications of cold therapy Correct Answer -Open
wounds (increases tissue damage)
-Impaired circulation
-Allergy or hypersensitive to cold
Contraindications of heat & cold therapy Correct Answer -
Neurosensory impairment
,-Impaired mental status
-Impaired circulation
-Open wounds
Contraindications of heat therapy Correct Answer -First 24
hours after surgery (increases bleeding & swelling)
-Active hemorrhage
-Noninflammatory edema
-Skin disorder that causes redness or blisters
Factors that decrease respiratory rate Correct Answer
Decreased environmental temp
Some medications
Increased intracranial pressure
Factors that increase respiratory rate Correct Answer Exercise
Stress
Increased environmental temp
Lowered oxygen concentration at higher altitudes
Fever Course Phase signs & symptoms Correct Answer
Absence of chills
Skin feels warm
Photosensitivity
Glassy-eyed
Increased pulse & respiratory rates
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness, delirium, or convulsion
Herpetic lesions of the mouth
Loss of appetite (prolonged fever)
, Malaise, weakness, and aching muscles
Fever Defervescence Phase signs & symptoms Correct Answer
Flushed & warm skin
Sweating
Decreased shivering
Possible dehydration
Fever Onset Phase signs & symptoms Correct Answer
Increased heart rate
Increased respiratory rate & depth
Shivering
Pallid, cold skin
Complains of feeling cold
Cyanotic, nail beds
Gooseflesh
Cessation of sweating
Heat exhaustion signs & symptoms Correct Answer Paleness
Dizziness
Nausea
Vomiting
Fainting
Moderately increased body temp (101 F to 102 F)
Heat stroke signs and symptoms Correct Answer Warm,
flushed skin
Absence of sweat
High body temp (106 F <)
Delirium
Unconsciousness
Complete Solutions
A purulent exudate is best described as: Correct Answer Thick
(due to pus), varied colors (green, blue, or yellow)
A serous exudate is best described as: Correct Answer thin,
watery, colorless exudate; example: fluid in a blister from a burn
Acute Pain NANDA (Wounds) Correct Answer Related to
nerve involvement within the tissue impairment or as a
consequence of procedures used to treat the wound.
Black wounds Correct Answer Are covered by thick necrotic
tissue, or eschar that requires debridement (removal of dead
tissue).
Blood pressure classifications Correct Answer - Normal = 90-
120/60-80
- Prehypertension = 120-139/80-89
- Stage 1 Hypertension = 140-159/90-99
- Stage 2 Hypertension = >160/>100
Braden scale categories Correct Answer sensory perception,
moisture, activity, mobility, nutrition, friction and shear
Can oxygen saturation assessments be delegated? Correct
Answer Yes. However, the RN is responsible for interpretation
of abnormal results.
,Clear absorbent acrylic dressing Correct Answer Description:
transparent absorbent wafer
Purpose: aids in easy wound assessment, protects against
bacteria and shearing, maintains moist wound healing.
Indications: pressure ulcers, skin tears, venous stasis ulcers,
surgical wounds, chemical debridement
Closed wound drainage system Correct Answer -Consists of a
drain connected to either an electric suction or a portable
drainage suction. Examples: hemovac, Jackson-Pratt
-Reduces the potential entry of microorganisms into the wound
through the drain.
Common NANDA diagnosis for skin wounds or risks for skin
breakdown Correct Answer -Risk for Pressure Ulcer
-Risk for Impaired Skin Integrity
-Impaired Skin Integrity
-Impaired Tissue Integrity
Common way heat leaves the body? Correct Answer Radiation
Conduction
Convection
Evaporation
Contraindications of cold therapy Correct Answer -Open
wounds (increases tissue damage)
-Impaired circulation
-Allergy or hypersensitive to cold
Contraindications of heat & cold therapy Correct Answer -
Neurosensory impairment
,-Impaired mental status
-Impaired circulation
-Open wounds
Contraindications of heat therapy Correct Answer -First 24
hours after surgery (increases bleeding & swelling)
-Active hemorrhage
-Noninflammatory edema
-Skin disorder that causes redness or blisters
Factors that decrease respiratory rate Correct Answer
Decreased environmental temp
Some medications
Increased intracranial pressure
Factors that increase respiratory rate Correct Answer Exercise
Stress
Increased environmental temp
Lowered oxygen concentration at higher altitudes
Fever Course Phase signs & symptoms Correct Answer
Absence of chills
Skin feels warm
Photosensitivity
Glassy-eyed
Increased pulse & respiratory rates
Increased thirst
Mild to severe dehydration
Drowsiness, restlessness, delirium, or convulsion
Herpetic lesions of the mouth
Loss of appetite (prolonged fever)
, Malaise, weakness, and aching muscles
Fever Defervescence Phase signs & symptoms Correct Answer
Flushed & warm skin
Sweating
Decreased shivering
Possible dehydration
Fever Onset Phase signs & symptoms Correct Answer
Increased heart rate
Increased respiratory rate & depth
Shivering
Pallid, cold skin
Complains of feeling cold
Cyanotic, nail beds
Gooseflesh
Cessation of sweating
Heat exhaustion signs & symptoms Correct Answer Paleness
Dizziness
Nausea
Vomiting
Fainting
Moderately increased body temp (101 F to 102 F)
Heat stroke signs and symptoms Correct Answer Warm,
flushed skin
Absence of sweat
High body temp (106 F <)
Delirium
Unconsciousness
