NSG-300 Exam 2 Topics 4-5 Questions with 100% Verified Correct Answers

NSG-300 Exam 2 Topics 4-5 Questions with 100% Verified Correct Answers what places patients at risk for pressure ulcers/impaired skin integrity - Correct Answer pressure intensity, pressure duration, tissue tolerance, impaired sensory perception, impaired mobility, alteration in LOC, shear, friction, moisture layers of the skin - Correct Answer epidermis, dermis (collagen) body's defenses against infection - Correct Answer normal flora, inflammatory response, immune response comprehensive wound assessment - Correct Answer -ongoing assessment from time of injury, wound care, any condition changes, and on scheduled basis -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 - Correct 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 - Correct Answer skin is intact but may be red or pink and warm to the touch; no blanching -for POC, there may be no noticeable blanching but skin color may vary type 2 ulcers - Correct Answer partial-thickness loss of dermis; shallow broken skin; red-pink wound bed type 3 ulcers - Correct 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