NURS 251 COMPREHENSIVE EXAM UPDATED
QUESTIONS AND ANSWERS SURE A+
✔✔proliferation phase - ✔✔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 - ✔✔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 - ✔✔dehydration
✔✔maceration - ✔✔overhydration
✔✔trauma - ✔✔physical injury
✔✔edema - ✔✔swelling caused by excess fluid trapped in your body's tissues
✔✔necrosis - ✔✔death of tissue
✔✔wound complications - ✔✔-infection
-hemorrhage
-dehiscence(wound separates) and evisceration(protrusion)
-fistula formation
✔✔Dehiscence - ✔✔Bursting open of a wound, especially a surgical abdominal wound
✔✔stages of pressure ulcers - ✔✔-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 - ✔✔-size of wound
-depth of wound
-presence of undermining, tunneling, or sinus tract(all on wound bed)
✔✔when measuring a wound - ✔✔measure from left to right and then top to bottom
✔✔friction - ✔✔occurs when two surfaces rub against each other
, ✔✔shear - ✔✔results when one layer of tissue slides over another layer
✔✔pressure ulcer - ✔✔wound with localized area of injury to the skin and/or underlying
tissue
✔✔fistula - ✔✔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 - ✔✔a cavity or channel underneath the wound that has the potential for
infection
✔✔cleaning a pressure ulcer - ✔✔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 - ✔✔clear and watery
✔✔sanguineous drainage - ✔✔blood cells present; looks like blood
✔✔serosanguineous drainage - ✔✔mix of serum and blood cells; light pink to blood
tinged
✔✔purulent drainage - ✔✔thick, musty or foul odor, varies in color
✔✔open drainage system - ✔✔penrose drain; promotes drainage passively
✔✔closed drainage system - ✔✔-Jackson-pratt drain
-hemovac drain
may be connected to an electrical suction or built-in reservoir
✔✔color classification of open wounds - ✔✔-R: red-protect
-Y: yellow-cleanse
-B: black-debride
-mixed wound: contains components of RY&B wounds
✔✔pain threshold - ✔✔the level at which a person experiences pain
✔✔pain tolerance - ✔✔the maximum level of pain that a person is able to tolerate
✔✔acute pain - ✔✔rapid in onset, varies in intensity and duration, protective in nature
✔✔chronic pain - ✔✔pain that may be limited, intermittent, or persistent but that lasts
beyond the normal healing period
QUESTIONS AND ANSWERS SURE A+
✔✔proliferation phase - ✔✔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 - ✔✔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 - ✔✔dehydration
✔✔maceration - ✔✔overhydration
✔✔trauma - ✔✔physical injury
✔✔edema - ✔✔swelling caused by excess fluid trapped in your body's tissues
✔✔necrosis - ✔✔death of tissue
✔✔wound complications - ✔✔-infection
-hemorrhage
-dehiscence(wound separates) and evisceration(protrusion)
-fistula formation
✔✔Dehiscence - ✔✔Bursting open of a wound, especially a surgical abdominal wound
✔✔stages of pressure ulcers - ✔✔-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 - ✔✔-size of wound
-depth of wound
-presence of undermining, tunneling, or sinus tract(all on wound bed)
✔✔when measuring a wound - ✔✔measure from left to right and then top to bottom
✔✔friction - ✔✔occurs when two surfaces rub against each other
, ✔✔shear - ✔✔results when one layer of tissue slides over another layer
✔✔pressure ulcer - ✔✔wound with localized area of injury to the skin and/or underlying
tissue
✔✔fistula - ✔✔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 - ✔✔a cavity or channel underneath the wound that has the potential for
infection
✔✔cleaning a pressure ulcer - ✔✔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 - ✔✔clear and watery
✔✔sanguineous drainage - ✔✔blood cells present; looks like blood
✔✔serosanguineous drainage - ✔✔mix of serum and blood cells; light pink to blood
tinged
✔✔purulent drainage - ✔✔thick, musty or foul odor, varies in color
✔✔open drainage system - ✔✔penrose drain; promotes drainage passively
✔✔closed drainage system - ✔✔-Jackson-pratt drain
-hemovac drain
may be connected to an electrical suction or built-in reservoir
✔✔color classification of open wounds - ✔✔-R: red-protect
-Y: yellow-cleanse
-B: black-debride
-mixed wound: contains components of RY&B wounds
✔✔pain threshold - ✔✔the level at which a person experiences pain
✔✔pain tolerance - ✔✔the maximum level of pain that a person is able to tolerate
✔✔acute pain - ✔✔rapid in onset, varies in intensity and duration, protective in nature
✔✔chronic pain - ✔✔pain that may be limited, intermittent, or persistent but that lasts
beyond the normal healing period
