NURS262 EXAM 2 REVIEW EXAM QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS GRADED A++
What is a clean contaminated wound?
surgical wounds in the GI, genital, or urinary tract; no evidence of infection
What is a contaminated wound?
open, accidental, and surgical wounds that involve a break in sterile technique or
spillage from the GI tract; evidence of inflammation
What is a dirty/defiled wound?
wounds with clinical infection (drainage or necrosis)
Wound bed considerations
partial or full thickness, granulation tissue, slough, eschar, exudate
Partial thickness wound bed
superficial skin layers (epidermal)
Full thickness wound bed
total loss of epidermis, dermis, and into subQ tissue
Granulation tissue
pink/red moist tissue composed of new blood vessels and connective tissue
Slough
soft, moist avascular tissue (white, yellow, tan, gray)
Eschar
black/brown necrotic tissue
, Exudate
accumulation of fluid within the wound
What are the possible characteristics (types) of exudate?
serous: thin clear or yellow tinged
sanguineous: bright red
serosanguineous: thin pink tinged exudate
purulent: pus
sanguinopurulent: pink cloudy exudate
What is important when changing a wound dressing?
consider administering pain medications beforehand
What are the characteristics of a stage 1 pressure injury?
-intact skin
-non-blanchable erythema
-change in sensation, temp, or firmness
What are the characteristics of a stage 2 pressure injury?
-partial thickness-->exposed dermis
-pink or red and moist wound bed
-no adipose or deeper tissue, granulation tissue, slough, or eschar
What are the characteristics of a stage 3 pressure injury?
-full thickness-->loss of epidermis and dermis-->down to SubQ
-adipose, slough, eschar, undermining, and tunneling seen
-no underlying bone structures such as: bone, muscle, tendon, and ligaments
What are the characteristics of a stage 4 pressure injury?
ANSWERS WITH COMPLETE SOLUTIONS GRADED A++
What is a clean contaminated wound?
surgical wounds in the GI, genital, or urinary tract; no evidence of infection
What is a contaminated wound?
open, accidental, and surgical wounds that involve a break in sterile technique or
spillage from the GI tract; evidence of inflammation
What is a dirty/defiled wound?
wounds with clinical infection (drainage or necrosis)
Wound bed considerations
partial or full thickness, granulation tissue, slough, eschar, exudate
Partial thickness wound bed
superficial skin layers (epidermal)
Full thickness wound bed
total loss of epidermis, dermis, and into subQ tissue
Granulation tissue
pink/red moist tissue composed of new blood vessels and connective tissue
Slough
soft, moist avascular tissue (white, yellow, tan, gray)
Eschar
black/brown necrotic tissue
, Exudate
accumulation of fluid within the wound
What are the possible characteristics (types) of exudate?
serous: thin clear or yellow tinged
sanguineous: bright red
serosanguineous: thin pink tinged exudate
purulent: pus
sanguinopurulent: pink cloudy exudate
What is important when changing a wound dressing?
consider administering pain medications beforehand
What are the characteristics of a stage 1 pressure injury?
-intact skin
-non-blanchable erythema
-change in sensation, temp, or firmness
What are the characteristics of a stage 2 pressure injury?
-partial thickness-->exposed dermis
-pink or red and moist wound bed
-no adipose or deeper tissue, granulation tissue, slough, or eschar
What are the characteristics of a stage 3 pressure injury?
-full thickness-->loss of epidermis and dermis-->down to SubQ
-adipose, slough, eschar, undermining, and tunneling seen
-no underlying bone structures such as: bone, muscle, tendon, and ligaments
What are the characteristics of a stage 4 pressure injury?
