Foundations of Nursing Exam Questions And 100% Correct
Verified Answers Grade A+ (GCU)
examples of proper nutrition that promotes wound healing - VERIFIED
ANSWER - - protein: chicken, eggs, fish, beef
- calories: protein smoothies, whole milk, beans, nuts, salmon
fluids
zinc, vitamin A and C
skin-associated issues in the older adult - VERIFIED ANSWER -
decreased cell turnover (healing takes more time), decreased fat
means bony prominences that can lead to ulcers, decreased barrier
function
who is at risk for pressure injuries? - VERIFIED ANSWER - older adults,
spinal cord injury, trauma, hip fracture, acutely ill or hospice, diabetes,
critical care settings
medical device related pressure injury - VERIFIED ANSWER - nasal
cannula, foley, tubing, cervical collars can all irritate skin and cause
breakdown. be sure to frequently assess these areas of skin for
breakdown
,how to assess for pressure injuries in patient with darker skin -
VERIFIED ANSWER - assess skin temperature and moisture, edema,
know baseline color and areas of redness
stage 1 pressure ulcer - VERIFIED ANSWER - Presence of blanchable
erythema or changes in sensation, temperature, or firmness may
precede visual changes. Color changes do not include purple or
maroon discoloration; these may indicate deep tissue pressure injury.
stage 2 pressure ulcer - VERIFIED ANSWER - Partial-thickness skin loss
with exposed dermis
stage 3 pressure ulcer - VERIFIED ANSWER - full-thickness skin loss
with exposed adipose tissue
stage 4 pressure ulcer - VERIFIED ANSWER - full-thickness skin loss
with exposed muscle, tendon, bone or fascia. if covered in slough and
eschar, it may be unstageable
Deep-tissue pressure injury - VERIFIED ANSWER - Intact or nonintact
skin with localized area of persistent nonblanchable deep red, maroon,
,purple discoloration, or epidermal separation revealing a dark wound
bed or blood-filled blister
surgical incision that is healing by primary intention - VERIFIED ANSWER
- wound that is closed
Secondary intention healing - VERIFIED ANSWER - wounds are not
approximated, may have tissue loss or contamination
good amount of scar tissue
serous fluid - VERIFIED ANSWER - clear, watery plasma
purulent exudate - VERIFIED ANSWER - Drainage which contains pus,
usually yellow, green or brown; indicates infection
Serosanginous fluid - VERIFIED ANSWER - pale, pink, watery; mixture of
clear and red fluid
most common immediately after surgery
sanginous fluid - VERIFIED ANSWER - bright red; indicates active
bleeding
, the nurse notices that her post-op patient hold their incision site, and
there is a significant increase in serosanginous fluid a few days after
surgery. what could be happening? - VERIFIED ANSWER - assess for
dehiscence: partial or total separation of wound layers from a sudden
strain
this requires immediate attention
the nurse notices a slight protrusion of organs from the client's
incision site. what should she do? - VERIFIED ANSWER - this is
evisceration, a medical emergency
1. place sterile soaked gauze over the extruding tissues
2. notify hcp and surgical team
3. do not allow the patient anything by mouth
4. prepare patient for emergency surgery
the nurse notices red, moist tissue at a wound site, what does this
mean? - VERIFIED ANSWER - granulation tissue most likely means
healing
eschar vs slough - VERIFIED ANSWER - eschar is black, brown, tan or
necrotic tissue
slough is a soft yellow stringy substance attached to the wound bed
both need to be removed (debrided) before healing can occur