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NSG-300 Exam 2 Exam with complete
solutions latest version
what places patients at risk for pressure ulcers/impaired skin integrity - CORRECT
ANSWER-pressure intensity, pressure duration, tissue tolerance, impaired sensory
perception, impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin - CORRECT ANSWER-epidermis, dermis (collagen)
body's defenses against infection - CORRECT ANSWER-normal flora, inflammatory
response, immune response
comprehensive wound assessment - CORRECT ANSWER--ongoing assessment from
time of injury, wound care, any condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description, response
to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - CORRECT ANSWER-assesses risk for developing pressure ulcers;
includes patient's sensory perception, moisture, activity, mobility, nutrition, friction and
shear; the lower the number the higher the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
type 1 ulcers - CORRECT ANSWER-skin is intact but may be red or pink and warm to
the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - CORRECT ANSWER-partial-thickness loss of dermis; shallow broken
skin; red-pink wound bed
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type 3 ulcers - CORRECT ANSWER-full-thickness tissue loss with visible fat
(subcutaneous layer); pale-yellow color; may include slough but does not obstruct view
of depth of injury
type 4 ulcers - CORRECT ANSWER-full-thickness tissue loss with exposed bone,
muscle, or tendon. possible tunneling and undermining
unstageable pressure ulcer - CORRECT ANSWER-base of ulcer covered by slough
and/or eschar in the wound bed so the depth is unknown; exudate;
deep tissue injury - CORRECT ANSWER-Purple or maroon localized area of discolored
intact skin or blood-filled blister due to damage of underlying soft tissue from pressure
and/or shear.
how should you clean a wound - CORRECT ANSWER-from least to most contaminated
eschar - CORRECT ANSWER-black, brown or necrotic tissue in wound bed; needs to
be removed before healing
slough - CORRECT ANSWER-stringy pale-yellowish tissue that lays in the wound bed;
needs to be removed before healing
if a patient has slough, eschar, and infectious exudate which one would you be most
concerned about - CORRECT ANSWER-infectious exudate
factors influencing heat and cold tolerance - CORRECT ANSWER-Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - CORRECT ANSWER-location, staging
(depth), type and % of tissue in wound bed, wound dimensions (including tunneling),
exudate description (if odor is present), and condition of surrounding skin
why is depth of an ulcer important - CORRECT ANSWER-because the wound heals
inside-out
granulation tissue - CORRECT ANSWER-good, fresh tissue that forms during the
healing of a wound (wound bed will be red, moist, and shiny)
How does a partial thickness wound heal? - CORRECT ANSWER-by regeneration
(scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate. 1st
24hrs after wounding.
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-epithelial proliferation (reproduction): starts at wound edges and epidermal cells lining
appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry wound,
the cells move down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and
appear as dry, pink tissue
How does a full thickness wound heal? - CORRECT ANSWER-by forming new
tissue/scar formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of
surrounding capillaries and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is filled
with replacement tissue (collagen, contraction, and granulation tissue), and the surface
is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for several
months. Collagen fibers undergo remodeling or reorganization before assuming their
normal appearance
primary intention - CORRECT ANSWER-wound that is closed/approximated; little tissue
loss; low risk of infection; quick healing with no scar usually (surgical incision)
secondary intention - CORRECT ANSWER-a wound with loss of tissue; wound is not
approximated; have to heal from the inside-out; if scarring is severe, loss of tissue
function may be permanent (pressure ulcers, surgical wound that has tissue loss)
tertiary intention - CORRECT ANSWER-Wound that is left open for several days, then
wound edges are approximated; doctor can monitor status of wound
complications of wound healing - CORRECT ANSWER-hemorrhage, infection,
dehiscence, evisceration
CMS - CORRECT ANSWER-created policy for hospitals to no longer receive additional
reimbursement for care related to eight conditions to improve quality of health care
signs and symptoms of wound infection - CORRECT ANSWER-Contaminated or
traumatic wounds: 2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
Dehiscence
Evisceration
what is needed for wound healing - CORRECT ANSWER-protein (albumin)
BRAINSCAPE1
NSG-300 Exam 2 Exam with complete
solutions latest version
what places patients at risk for pressure ulcers/impaired skin integrity - CORRECT
ANSWER-pressure intensity, pressure duration, tissue tolerance, impaired sensory
perception, impaired mobility, alteration in LOC, shear, friction, moisture
layers of the skin - CORRECT ANSWER-epidermis, dermis (collagen)
body's defenses against infection - CORRECT ANSWER-normal flora, inflammatory
response, immune response
comprehensive wound assessment - CORRECT ANSWER--ongoing assessment from
time of injury, wound care, any condition changes, and on scheduled basis
-Important to include cause of injury, history of wound, treatment, description, response
to therapy
-Braden scale: assesses risk for pressure/skin injury every shift
Braden Scale - CORRECT ANSWER-assesses risk for developing pressure ulcers;
includes patient's sensory perception, moisture, activity, mobility, nutrition, friction and
shear; the lower the number the higher the risk
>9= very high risk
10-12= high risk
13-14= moderate risk
15-18= mild risk
19-23= generally not at risk
type 1 ulcers - CORRECT ANSWER-skin is intact but may be red or pink and warm to
the touch; no blanching
-for POC, there may be no noticeable blanching but skin color may vary
type 2 ulcers - CORRECT ANSWER-partial-thickness loss of dermis; shallow broken
skin; red-pink wound bed
BRAINSCAPE1
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type 3 ulcers - CORRECT ANSWER-full-thickness tissue loss with visible fat
(subcutaneous layer); pale-yellow color; may include slough but does not obstruct view
of depth of injury
type 4 ulcers - CORRECT ANSWER-full-thickness tissue loss with exposed bone,
muscle, or tendon. possible tunneling and undermining
unstageable pressure ulcer - CORRECT ANSWER-base of ulcer covered by slough
and/or eschar in the wound bed so the depth is unknown; exudate;
deep tissue injury - CORRECT ANSWER-Purple or maroon localized area of discolored
intact skin or blood-filled blister due to damage of underlying soft tissue from pressure
and/or shear.
how should you clean a wound - CORRECT ANSWER-from least to most contaminated
eschar - CORRECT ANSWER-black, brown or necrotic tissue in wound bed; needs to
be removed before healing
slough - CORRECT ANSWER-stringy pale-yellowish tissue that lays in the wound bed;
needs to be removed before healing
if a patient has slough, eschar, and infectious exudate which one would you be most
concerned about - CORRECT ANSWER-infectious exudate
factors influencing heat and cold tolerance - CORRECT ANSWER-Exposure time
Exposed skin
Temperature
Age
Perception of sensory stimuli
assessment for pressure ulcers includes - CORRECT ANSWER-location, staging
(depth), type and % of tissue in wound bed, wound dimensions (including tunneling),
exudate description (if odor is present), and condition of surrounding skin
why is depth of an ulcer important - CORRECT ANSWER-because the wound heals
inside-out
granulation tissue - CORRECT ANSWER-good, fresh tissue that forms during the
healing of a wound (wound bed will be red, moist, and shiny)
How does a partial thickness wound heal? - CORRECT ANSWER-by regeneration
(scratch or abrasion)
-inflammatory response: redness/swelling to area with moderate serous exudate. 1st
24hrs after wounding.
BRAINSCAPE1
, BRAINSCAPE1
-epithelial proliferation (reproduction): starts at wound edges and epidermal cells lining
appendages (quick resurfacing)
-epithelial migration: epithelial cells only migrate in a moist environment. in dry wound,
the cells move down into a moist level before resurfacing can happen
-reestablishment of epidermal layers: cells slowly establish normal thickness and
appear as dry, pink tissue
How does a full thickness wound heal? - CORRECT ANSWER-by forming new
tissue/scar formation, which takes longer (pressure ulcers)
-hemostasis: injured vessels constrict and platelets gather to stop bleeding
-inflammation: damaged tissue and mast cells secrete histamine (vasodilation of
surrounding capillaries and movement of serum and WBCs into damaged tissue)
-proliferation: the vascular bed is reestablished (granulation tissue), the area is filled
with replacement tissue (collagen, contraction, and granulation tissue), and the surface
is repaired (epithelialization)
-maturation: The collagen scar continues to reorganize and gain strength for several
months. Collagen fibers undergo remodeling or reorganization before assuming their
normal appearance
primary intention - CORRECT ANSWER-wound that is closed/approximated; little tissue
loss; low risk of infection; quick healing with no scar usually (surgical incision)
secondary intention - CORRECT ANSWER-a wound with loss of tissue; wound is not
approximated; have to heal from the inside-out; if scarring is severe, loss of tissue
function may be permanent (pressure ulcers, surgical wound that has tissue loss)
tertiary intention - CORRECT ANSWER-Wound that is left open for several days, then
wound edges are approximated; doctor can monitor status of wound
complications of wound healing - CORRECT ANSWER-hemorrhage, infection,
dehiscence, evisceration
CMS - CORRECT ANSWER-created policy for hospitals to no longer receive additional
reimbursement for care related to eight conditions to improve quality of health care
signs and symptoms of wound infection - CORRECT ANSWER-Contaminated or
traumatic wounds: 2-3 days
Post op surgical wound: 4-5 days
Fever, tenderness and pain at wound site
Elevated WBC count
Wound edges appear inflamed
Drainage may be present: odorous and purulent (yellow, green, or brown)
Dehiscence
Evisceration
what is needed for wound healing - CORRECT ANSWER-protein (albumin)
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