NURS 134 COMPREHENSIVE REVIEW
QUESTIONS AND CORRECT ANSWERS 2026
> wound complications? Answer:-infection
-hemorrhage
-dehiscence(wound separates) and evisceration(protrusion)
-fistula formation
> Dehiscence? Answer:Bursting open of a wound, especially a surgical
abdominal wound
> stages of pressure ulcers? Answer:-stage1: nonblanchable erythema of
intact skin
-stage2: partial-thickness skin loss
-stage3: full-thickness skin loss; not involving underlying fascia( epidermis
and dermis)
-stage4: full-thickness skin loss with extensive destruction (epidermis,
dermis, and subcutaneous)
-unstageable: base of ulcer covered by slough and/or eschar in wound bed
> measurement of pressure ulcer? Answer:-size of wound
-depth of wound
-presence of undermining, tunneling, or sinus tract(all on wound bed)
> when measuring a wound? Answer:measure from left to right and then
top to bottom
> friction? Answer:occurs when two surfaces rub against each other
> shear? Answer:results when one layer of tissue slides over another layer
> pressure ulcer? Answer:wound with localized area of injury to the skin
and/or underlying tissue
, > fistula? Answer:and abnormal passage from an internal organ or vessel
to the outside of the body or from one internal organ or vessel to another
> sinus tract? Answer:a cavity or channel underneath the wound that has
the potential for infection
> cleaning a pressure ulcer? Answer:clean w/ each dressing change,
gentle motions (patting), use 0.9% normal saline solution to irrigate and
clean, report any drainage or necrotic tissue
> serous drainage? Answer:clear and watery
> sanguineous drainage? Answer:blood cells present; looks like blood
> serosanguineous drainage? Answer:mix of serum and blood cells; light
pink to blood tinged
> purulent drainage? Answer:thick, musty or foul odor, varies in color
> open drainage system? Answer:penrose drain; promotes drainage
passively
> closed drainage system? Answer:-Jackson-pratt drain
-hemovac drain
may be connected to an electrical suction or built-in reservoir
> color classification of open wounds? Answer:-R: red-protect
-Y: yellow-cleanse
-B: black-debride
-mixed wound: contains components of RY&B wounds
> pain threshold? Answer:the level at which a person experiences pain
> pain tolerance? Answer:the maximum level of pain that a person is able
to tolerate
> acute pain? Answer:rapid in onset, varies in intensity and duration,
protective in nature
QUESTIONS AND CORRECT ANSWERS 2026
> wound complications? Answer:-infection
-hemorrhage
-dehiscence(wound separates) and evisceration(protrusion)
-fistula formation
> Dehiscence? Answer:Bursting open of a wound, especially a surgical
abdominal wound
> stages of pressure ulcers? Answer:-stage1: nonblanchable erythema of
intact skin
-stage2: partial-thickness skin loss
-stage3: full-thickness skin loss; not involving underlying fascia( epidermis
and dermis)
-stage4: full-thickness skin loss with extensive destruction (epidermis,
dermis, and subcutaneous)
-unstageable: base of ulcer covered by slough and/or eschar in wound bed
> measurement of pressure ulcer? Answer:-size of wound
-depth of wound
-presence of undermining, tunneling, or sinus tract(all on wound bed)
> when measuring a wound? Answer:measure from left to right and then
top to bottom
> friction? Answer:occurs when two surfaces rub against each other
> shear? Answer:results when one layer of tissue slides over another layer
> pressure ulcer? Answer:wound with localized area of injury to the skin
and/or underlying tissue
, > fistula? Answer:and abnormal passage from an internal organ or vessel
to the outside of the body or from one internal organ or vessel to another
> sinus tract? Answer:a cavity or channel underneath the wound that has
the potential for infection
> cleaning a pressure ulcer? Answer:clean w/ each dressing change,
gentle motions (patting), use 0.9% normal saline solution to irrigate and
clean, report any drainage or necrotic tissue
> serous drainage? Answer:clear and watery
> sanguineous drainage? Answer:blood cells present; looks like blood
> serosanguineous drainage? Answer:mix of serum and blood cells; light
pink to blood tinged
> purulent drainage? Answer:thick, musty or foul odor, varies in color
> open drainage system? Answer:penrose drain; promotes drainage
passively
> closed drainage system? Answer:-Jackson-pratt drain
-hemovac drain
may be connected to an electrical suction or built-in reservoir
> color classification of open wounds? Answer:-R: red-protect
-Y: yellow-cleanse
-B: black-debride
-mixed wound: contains components of RY&B wounds
> pain threshold? Answer:the level at which a person experiences pain
> pain tolerance? Answer:the maximum level of pain that a person is able
to tolerate
> acute pain? Answer:rapid in onset, varies in intensity and duration,
protective in nature
