NURS 326 Midterm Exam Practice Questions and Answers

NURS 326 Midterm Exam Practice Questions and Answers What is ischemia? - Ans:-inadequate blood supply to organ or part of the body What is shear? - Ans:-force extended parallel to skin How does moisture contribute to skin integrity complications? - Ans:-Moisture softens skin which increases risk for skin breakdown Primary intention? - Ans:-Skin edges are approximated. Healing occurs by epithelialization; heals quickly with minimal scar formation Secondary intention? - Ans:-Wound edges are not approximated. Wound heals by granulation tissue formation, wound contraction, and epithelialization. Chance of infection is greater. Healing takes longer. Hemostasis? - Ans:-Cessation of bleeding Dehiscence? - Ans:-The partial or total separation of would layer Evisceration? - Ans:-Protrusion of visceral organs through a wound opening, occur with total separation of would layers ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/8 What is the second most common HAI? - Ans:-Wound infection Blanchable Hyperemia? - Ans:-Redness on the skin that turns lighter in color when pressure is applied, and the erythema returns when finger is removed. It is transient and an attempt to overcome the ischemic episode. If your patient is experiencing excessive exudate, it may indicate? - Ans:-An infection Hematoma? - Ans:-Localized collection of blood underneath the tissues. appears as swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. Your patient is experiencing redness over a bony prominence. Should you, the RN, massage the area to increase blood flow? - Ans:-No. NEVER MASSAGE A REDDENED AREA (or bony prominence). It increases breakdown of capillary and underlying tissue. Your nursing assistant has just finished repositioning a patient. They tell you, "I cannot remember what degree to position the head at, can you remind me?" What is your response/answer? - Ans:-Maintain the head of bed at or below a 30-degree angle, or flat, to relieve pressure on sacrum, buttocks, and heels How often will a skin assessment and Braden scale be used? - Ans:-EVERY shift Lower the total score is on the Braden scale, the _____ the risk for the development of a pressure ulcer is. - Ans:-Higher ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/8 What are the 6 subscales on the Braden scale? - Ans:-FAN MM'S - Friction and shear, Activity, Nutrition, Mobility, Moisture, and Sensory perception Your patient has full thickness skin and tissue loss, with visual fat. What stage pressure ulcer is this? - Ans:-Stage 3. Stage 1: intact skin, w/ non-blanchable redness. Stage 2: Partial thickness, epidermis skin loss. Stage 3: Full thickness skin & tissue loss, with visual fat. Stage 4: Full thickness & skin tissue loss, with visual bone muscle/tendon Tissue perfusion is one of the factors that influence pressure ulcer formation and wound healing. True or False. - Ans:-True. Abrasion? - Ans:-Superficial with little bleeding and is considered a