NURS 134 EXAM PREPARATION QUESTIONS
WITH FULL RATIONALES 2026
> inflammatory phase? Answer:follows hemostasis and lasts 4-6 days,
white blood cells move to wound, macrophages enter wound and remain
extended time, they ingest debris and release growth factors, pt has
generalized body repsonse
> proliferation phase? Answer:begins 2-3 days of injury and may last up to
2-3 weeks, new tissue is built to fill wound space through action of
fibroblasts, capillaries grow across wound, thin layer of epithelial cells form
across wound, granulation tissue forms a foundation for scar tissue to
develop
> maturation phase? Answer:final stage of healing, begins 3 weeks to 6
months after injury, collagen remodeled, new collagen tissue is deposited,
scar becomes thin white line
> desiccation? Answer:dehydration
> maceration? Answer:overhydration
> trauma? Answer:physical injury
> edema? Answer:swelling caused by excess fluid trapped in your body's
tissues
> necrosis? Answer:death of tissue
> 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
WITH FULL RATIONALES 2026
> inflammatory phase? Answer:follows hemostasis and lasts 4-6 days,
white blood cells move to wound, macrophages enter wound and remain
extended time, they ingest debris and release growth factors, pt has
generalized body repsonse
> proliferation phase? Answer:begins 2-3 days of injury and may last up to
2-3 weeks, new tissue is built to fill wound space through action of
fibroblasts, capillaries grow across wound, thin layer of epithelial cells form
across wound, granulation tissue forms a foundation for scar tissue to
develop
> maturation phase? Answer:final stage of healing, begins 3 weeks to 6
months after injury, collagen remodeled, new collagen tissue is deposited,
scar becomes thin white line
> desiccation? Answer:dehydration
> maceration? Answer:overhydration
> trauma? Answer:physical injury
> edema? Answer:swelling caused by excess fluid trapped in your body's
tissues
> necrosis? Answer:death of tissue
> 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
