NUR 155 EXAM 3 (UNIT 6-7)
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS 100%
CORRECT!!! (GRADED A+)
prioritizing and Triaging Highest Clinical Risk
When managing a group of patients, look for specific compounding factors to
identify who is at the greatest risk for rapid skin breakdown or severe infection:
Extremes of Age: Fragile neonatal skin or compromised, thin elderly skin
tissues.
Active Infection: Systemic or localized pathogens increase metabolic
demands and impair wound repair mechanisms.
Presence of Medical Devices: Tubing, masks, cervical collars, or lines can
apply unrecognized, localized mechanical pressure.
Uncontrolled Diabetes: Compromises microvascular circulation and nerve
sensation (neuropathy), which limits the patient's ability to feel localized
discomfort.
Initial Stages of Pressure Injuries
To accurately stage an early-stage localized pressure injury, look for the following
anatomical markers:
Stage 1 Pressure Injury: The skin surface remains entirely intact,
presenting with a localized area of non-blanchable erythema (redness that
does not temporarily turn white when pressed). The area may also exhibit
changes in temperature (warmer or cooler), firmness, or sensation compared
to the surrounding tissues.
Stage 2 Pressure Injury: Characterized by partial-thickness skin loss with
an exposed dermis layer. The wound bed presents as a shallow, pink or red,
moist surface without slough or bruising. This stage may also manifest as an
intact or ruptured serum-filled blister.
,Stage 3 pressure injury -ANSWER ✔✔full-thickness skin loss reaching
subcutaneous tissue, potential undermining (tissue loss under intact skin, "lip"),
and tunneling
Stage 4 pressure injury -ANSWER ✔✔Full-thickness skin and tissue loss,
osteomyelitis, exposure to muscle, bone, or connective tissue
Unstageable pressure injury -ANSWER ✔✔full-thickness skin & tissue loss,
unable to assess depth until eschar is removed
Deep tissue pressure injury -ANSWER ✔✔intact persistent, nonblanchable, deep
red, maroon, purple discoloration
Ture or False
as healing takes place, a pressure injury will not be able to return to a normal state
prior to injury -ANSWER ✔✔True
Serous Drainage -ANSWER ✔✔contains clear/yellow watery fluid from plasma
Serosanguineous Draingage -ANSWER ✔✔pink - pale red, mix of serous fluid and
red/bloody fluid
Sanguineous -ANSWER ✔✔indicates bleeding, bright red.
Purulent -ANSWER ✔✔thick, yellow-greenish-beige, indicates infection
, Dehiscence -ANSWER ✔✔PARTIAL/COMPLETE separation of tissue layers
during the healing process
Evisceration -ANSWER ✔✔-TOTAL separation of tissue layers, causing
protrusion of visceral organs
"popping" sensation
caring for dehiscence or evisceration -ANSWER ✔✔-cover wound with sterile
saline-moistened gauze
- notify provider
How to identify an infected wound -ANSWER ✔✔visible redness, warmth,
increased drainage, MAY or MAY NOT be purulent
Primary intention healing -ANSWER ✔✔ACUTE WOUND= heals quickly,
minimal scar formation
ex: surgical incisions, traumatic wounds
Secondary intention healing -ANSWER ✔✔CHRONIC WOUND= stay open for
period of time to allow for drainage and observation, once infection lowers it is
closed, new tissue growth begins from BOTTOM-TOP
Tertiary intention healing -ANSWER ✔✔CHRONIC WOUND= delay occurs
between injury and closure
ex: G.I tract surgery
Vitamins aiding in healing of pressure wounds -ANSWER ✔✔A.C.E
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS 100%
CORRECT!!! (GRADED A+)
prioritizing and Triaging Highest Clinical Risk
When managing a group of patients, look for specific compounding factors to
identify who is at the greatest risk for rapid skin breakdown or severe infection:
Extremes of Age: Fragile neonatal skin or compromised, thin elderly skin
tissues.
Active Infection: Systemic or localized pathogens increase metabolic
demands and impair wound repair mechanisms.
Presence of Medical Devices: Tubing, masks, cervical collars, or lines can
apply unrecognized, localized mechanical pressure.
Uncontrolled Diabetes: Compromises microvascular circulation and nerve
sensation (neuropathy), which limits the patient's ability to feel localized
discomfort.
Initial Stages of Pressure Injuries
To accurately stage an early-stage localized pressure injury, look for the following
anatomical markers:
Stage 1 Pressure Injury: The skin surface remains entirely intact,
presenting with a localized area of non-blanchable erythema (redness that
does not temporarily turn white when pressed). The area may also exhibit
changes in temperature (warmer or cooler), firmness, or sensation compared
to the surrounding tissues.
Stage 2 Pressure Injury: Characterized by partial-thickness skin loss with
an exposed dermis layer. The wound bed presents as a shallow, pink or red,
moist surface without slough or bruising. This stage may also manifest as an
intact or ruptured serum-filled blister.
,Stage 3 pressure injury -ANSWER ✔✔full-thickness skin loss reaching
subcutaneous tissue, potential undermining (tissue loss under intact skin, "lip"),
and tunneling
Stage 4 pressure injury -ANSWER ✔✔Full-thickness skin and tissue loss,
osteomyelitis, exposure to muscle, bone, or connective tissue
Unstageable pressure injury -ANSWER ✔✔full-thickness skin & tissue loss,
unable to assess depth until eschar is removed
Deep tissue pressure injury -ANSWER ✔✔intact persistent, nonblanchable, deep
red, maroon, purple discoloration
Ture or False
as healing takes place, a pressure injury will not be able to return to a normal state
prior to injury -ANSWER ✔✔True
Serous Drainage -ANSWER ✔✔contains clear/yellow watery fluid from plasma
Serosanguineous Draingage -ANSWER ✔✔pink - pale red, mix of serous fluid and
red/bloody fluid
Sanguineous -ANSWER ✔✔indicates bleeding, bright red.
Purulent -ANSWER ✔✔thick, yellow-greenish-beige, indicates infection
, Dehiscence -ANSWER ✔✔PARTIAL/COMPLETE separation of tissue layers
during the healing process
Evisceration -ANSWER ✔✔-TOTAL separation of tissue layers, causing
protrusion of visceral organs
"popping" sensation
caring for dehiscence or evisceration -ANSWER ✔✔-cover wound with sterile
saline-moistened gauze
- notify provider
How to identify an infected wound -ANSWER ✔✔visible redness, warmth,
increased drainage, MAY or MAY NOT be purulent
Primary intention healing -ANSWER ✔✔ACUTE WOUND= heals quickly,
minimal scar formation
ex: surgical incisions, traumatic wounds
Secondary intention healing -ANSWER ✔✔CHRONIC WOUND= stay open for
period of time to allow for drainage and observation, once infection lowers it is
closed, new tissue growth begins from BOTTOM-TOP
Tertiary intention healing -ANSWER ✔✔CHRONIC WOUND= delay occurs
between injury and closure
ex: G.I tract surgery
Vitamins aiding in healing of pressure wounds -ANSWER ✔✔A.C.E
