NSG-300 EXAM 2 ACTUAL QUESTIONS AND

NSG-300 EXAM 2 ACTUAL / QUESTIONS AND

VERIFIED CORRECT ANSWERS,

Braden Scale - ----Answers---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 - ----Answers---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 - ----Answers---partial-thickness loss of dermis; shallow broken skin; red-pink wound bed

type 3 ulcers - ----Answers---full-thickness tissue loss with visible fat (subcutaneous layer); pale-yellow color; may include slough but does not obstruct view of depth of injury

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type 4 ulcers - ----Answers---full-thickness tissue loss with exposed bone, muscle, or tendon. possible tunneling and undermining

unstageable pressure ulcer - ----Answers---base of ulcer covered by slough and/or eschar in the wound bed so the depth is unknown; exudate;

deep tissue injury - ----Answers---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 - ----Answers---from least to most contaminated

eschar - ----Answers---black, brown or necrotic tissue in wound bed; needs to be removed before healing

slough - ----Answers---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 - ----Answers--- infectious exudate

factors influencing heat and cold tolerance - ----Answers--- Exposure time 2 / 4

Exposed skin Temperature Age Perception of sensory stimuli

assessment for pressure ulcers includes - ----Answers--- 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 - ----Answers---because the wound heals inside-out

granulation tissue - ----Answers---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? - ----Answers---by regeneration (scratch or abrasion)

-inflammatory response: redness/swelling to area with

moderate serous exudate. 1st 24hrs after wounding.

-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 3 / 4

-reestablishment of epidermal layers: cells slowly establish

normal thickness and appear as dry, pink tissue

How does a full thickness wound heal? - ----Answers---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 - ----Answers---wound that is closed/approximated; little tissue loss; low risk of infection; quick healing with no scar usually (surgical incision)

secondary intention - ----Answers---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)

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