NR 224 Fundamentals Exam ACTUAL EXAM COMPLETE - QUESTIONS AND CORRECT DETAILED ANSWERS

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NR 224 Fundamentals Exam 2 2024-2025 ACTUAL EXAM COMPLETE -

QUESTIONS AND CORRECT DETAILED ANSWERS

Quiz Acute wounds

Ans: trauma and surgical

Quiz Chronic

Ans: vascular compromise

Quiz Pressure Ulcers

Ans: Impaired skin integrity r/t unrelieved , prolonged pressure in combination with
shear or friction. (bed sores)

Quiz At risk pressure ulcer pt...

Ans: Impaired sensory
Spinal cord injuries
Immobile patients
Shear/Friction
Moisture
Altered level of consciousness

Quiz Stage 1 pressure ulcer

Ans: - Nonblanchable erythema
-Skin remains intact
Nursing Dx: (Ineffective tissue perfusion)

Quiz Stage II Pressure Ulcer

Ans: - open skin wound
- shallow
- red/pink color

, Quiz Stage III Pressure Ulcer

Ans: - full thickness tissue loss
- subcutaneous fat visible

Quiz Stage IV Pressure Ulcer

Ans: - exposed bone, muscle or tendon
- tunneling and undermining needed

Quiz Unstageable Pressure Ulcer

Ans: - completely covered in slough
- some of wound can be necrotic
- difficult to stage
- after deprevement stage can be determined

Quiz Suspected Deep Tissue Ulcer

Ans: purple localized area of discolored intact skin blood filled blister.
-mushy
- warm or cool

Quiz Pressure Ulcer Assessment and documentation

Ans: Location
Wound Bed
-Tunneling
-Undermining
-Granulation tissue
-Slough
-Eschar
Drainage
Odor
Size
LxW
Depth
Pain
Dressing change
Dressing type
Cleaning solution
How the patient tolerated the procedure!

Quiz Undermining

Ans: Caused by erosion under the wound edges
resulting in a large wound with a small opening.

Quiz Clock terms are used to describe the location of undermining