Foundations of Nursing Exam Questions And 100% Correct
Verified Answers Grade A+ (GCU
A nurse states slough is present in a stage 3 pressure injury. What
should the student nurse expect to see? - VERIFIED ANSWER - A yellow
or white, stringy substance attached to wound bed
A nurse states eschar is present in a stage 4 pressure injury. What
should the student nurse expect to see? - VERIFIED ANSWER - brown or
black necrotic tissue
A nurse states that they gathered the assessment information from a
primary source. How did the nurse obtain the information? - VERIFIED
ANSWER - From the patient
A nurse states that they gathered the assessment information from a
secondary source. How did the nurse obtain the information? -
VERIFIED ANSWER - From family, HCP and medical records
A health care provider may suspect that a patient is experiencing
urinary retention when the patient has - VERIFIED ANSWER - small
amount of urine voided 2-3 times per hour
,What growth and developmental considerations should the nurse keep
in mind in regards to urine elimination? - VERIFIED ANSWER - Determine
the patient's ability to control the act of urination across life span and
pregnancy causes changes to urinary tract
What psychosocial implications considerations should the nurse keep in
mind in regards to urine elimination? - VERIFIED ANSWER - micturition
should be private and incontinence can be devastating to self-image
and self-esteem
What are 3 pressure related factors that contribute to pressure ulcer
development? - VERIFIED ANSWER - 1. Pressure Intensity
2. Pressure Duration
3. Tissue Tolerance
How does pressure lead to tissue ischemia? - VERIFIED ANSWER - If
pressure applied over a capillary exceeds normal capillary pressure
and the vessel is occluded for a prolonged time
What occurs is tissue ischemia is left untreated? - VERIFIED ANSWER -
tissue death
,Does blanching occur in dark skinned patients? - VERIFIED ANSWER -
No, blanching does not occur but color, texture and temp may differ
from surrounding area
What does pressure duration assess? - VERIFIED ANSWER - Low and
extended pressures
- Low pressure over a prolonged time causes tissue damage
- Extended pressure occludes blood flow and nutrients causing tissue
death
What is tissue tolerance? - VERIFIED ANSWER - the ability of tissue to
endure pressure which is dependent on the integrity of the tissue and
supporting structures
What are risk factors of pressure injuries? - VERIFIED ANSWER -
◦Impaired sensory perception
◦Impaired mobility
◦Alteration in LOC
◦Shear
◦Friction
◦Moisture
, What should the nurse look for when assessing a pressure injury? -
VERIFIED ANSWER - Wound location, staging, type and approximate
percentage of tissue in wound bed, wound dimensions (sinus tracts and
tunneling), exudate description and condition of surrounding skin
stage 1 pressure injury - VERIFIED ANSWER - Intact skin with
nonblanchable redness
stage 2 pressure injury - VERIFIED ANSWER - partial thickness skin loss
involving epidermis, dermis or both and, shallow abrasion or open
blister looking
stage 3 pressure injury - VERIFIED ANSWER - full thickness skin loss
extending to SQ, crater looking
stage 4 pressure injury - VERIFIED ANSWER - full thickness with
exposed bone, muscle or tendon and may have eschar
What characteristics does stage 3 and 4 pressure injuries share? -
VERIFIED ANSWER - They may have slough, undermining and tunneling
present