Examl 2:l NSGl 300/l NSG300l (Latestl 2025/l
2026l Update)l Foundationsl ofl Nursingl Guide|l Questionsl &l Answers|l Gradel A|l 100%l Correctl (Verifiedl Solutions)-l GCU
Q:l complicationsl ofl woundl healing
Answer:
HEMORRHAGE
-bleedingl froml thel woundl site -bleedingl isl normall duringl andl rightl after >butl continuedl bleedingl couldl indicate:l infection,l clot,l bvl damagel byl foreignl object,l suturel isl loose -internall bleeding:l swelling/distention,l changel inl type/amountl ofl drainage,l hypovolemicl shock
-external:l lookl atl woundl dressingl orl thel bedl underl thel patientl
INFECTION
-inl acutel care,l surgicall sitel infectionsl arel al bigl problem -microl ol arel transmittedl tol woundl sitel byl contact,l air,l orl theyl spreadl froml otherl partsl ofl thel bodyl intol thel wound -thel microl ol invadel thel woundl tissuel andl youl canl telll ifl thel woundl isl infectedl by:l redness,l increasedl drainage,l changel inl drainagel characteristicsl (thick,l odor,l color).l canl alsol telll byl periwoundl edema,l pain,l orl warmth.l personl mayl havel feverl orl increasedl WBCl (orderl labl tests)
DEHISCENCE
-totall orl partiall separationl ofl woundl layers,l typicallyl beforel collagenl formation -ppll atl risk:l poorl nutrition,l infection,l underlyingl diseasesl (PVDl orl typel 2) -occursl 5l tol 12l daysl afterl suturing,l whenl woundl healingl isl atl itsl peak -ifl therel isl anl increasel inl serosanguineousl fluid,l lookl forl this
EVISCERATION
-whenl viscerall organsl protrudel outl ofl al completel dehiscence,l thisl isl anl emergency,l needl surgeryl asap -ifl thisl happens,l coverl thel tissuel withl sterilel gauzel soakedl inl salinel tol preventl dryingl ofl tissuesl andl infection -thel bloodl supplyl tol thel organsl mayl bel diminished -alertl surgicall team,l instructl patientl tol notl takel anythingl byl mouth,l lookl s/sl ofl shock,l preparel patientl forl surgery
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Q:l predictl andl preventl pressurel injuries
Answer:
byl identifyingl whatl patientsl arel atl risk,l itl allowsl youl tol applyl preventativel measuresl andl sparel lowl riskl patientsl ofl unnecessary/costlyl treatments -canl usel bradenl scalel tol assessl risk:l moisture,l sensoryl perception,l friction/shear,l immobility,l activity,l nutrition >al lowl scorel meansl highl risk -thel occurrencel ofl al pressurel injuryl causesl al longerl hospitall stayl andl isl morel costly >costsl patientsl inl termsl ofl pain,l suffering,l disturbance >Medicarel andl Medicaidl nol longerl reimbursel hospitalsl forl carel ofl stagel 3l andl 4l thatl occurredl inl thel hospital
Q:l factorsl influencingl pressurel injuryl formationl andl woundl healing
Answer:
NUTRITION
-deficienciesl inl anyl ofl thel nutrientsl causesl impairedl healing -especiallyl needl vitaminsl (A+C),l protein,l andl tracel mineralsl (copperl andl zinc)l tol providel thel energyl forl healing -proteinl neededl forl tissuel repairl andl growth
PERFUSION
-oxygenl fuelsl thel cellularl needsl ofl woundl healing,l goodl perfusionl isl necessary AGE PSYCHOSOCIALl IMPACTl OFl WOUNDS -bodyl imagel changesl canl resultl froml wounds,l thisl putsl stressl onl thel adaptivel systemsl ofl thel client -alsol influencesl theirl selfl conceptl andl sexuality
INFECTION
-infectionl prolongsl thel inflaml process
Q:l assessment:l skinl integrityl andl woundl care
Answer:
-thoroughlyl assessl thel skinl integrityl ofl thel patient -ifl thel knowledgel youl havel abtl thel patientl suggestsl thatl theyl arel atl riskl ofl pressurel injury,l closelyl assessl thosel areasl andl thel thingsl thatl mayl bel causingl itl (sensoryl perception,l medl device) 2 / 4
-knowl thel clientsl expectations:l ifl theyl havel realisticl expectationsl theyl arel morel likelyl tol adherel tol carel plan -assessl forl environmentall factorsl thatl couldl getl inl thel wayl ofl assessment:l oftenl clientsl willl needl repositioningl andl turning >observel whenl familyl membersl arel typicallyl inl thel rooml andl planl complexl woundl dressingl changesl aroundl that.l thisl willl allowl forl privacyl andl controll ofl infection SKIN -assessl thel typel ofl tissuel inl thel woundl bedl andl anyl factorsl thatl couldl preventl woundl healing WOUNDSl ANDl PRESSUREl INJURIES -lookl atl thel amountl (%),l appearancel (color)l ofl viablel andl nonl viablel tissue >granulationl tissue:l red,l moist,l composedl ofl newl bvl (indicatesl healing) >slough:l yellow/white,l stringyl substancel attachedl tol thel woundl bedl (needsl removal)
>eschar:l tan,l brown,l black,l orl necroticl tissue.l needsl removal
>measure:l dimensionsl canl indicatel healing,l L/W/H
>exudate:l amount,l color,l consistency,l odor.l typicallyl closedl woundsl dontl havel al lotl ofl serosanguinousl fluid.l excessivel amountsl canl indicatel infection -whenl youl locatel al woundl lookl atl type,l location,l amount,l pain,l distribution,l quality,l intensity,l aggravating/relievingl factors -lookl atl periwoundl skin:l red,l warm,l signsl ofl maceration,l palpatel forl pain
usel predictivel measuresl tol assess:
-nutrition -mobility -pain:l relievel painl sol clientl isl morel willingl tol increasel activity,l whichl willl reducel thel riskl ofl pressurel injury
-bodyl fluids:l causel thel skinl tol breakdown
SURGICALl ANDl TRAUMAl WOUNDS -emergencyl setting:l assessl woundl whenl itl occurs,l duringl woundl care,l whenl clientsl conditionl changes,l andl onl al regularl scheduledl basis.l lookl forl forei
Q:l diagnosis:l skinl integrityl andl woundl care
Answer:
-riskl infection -acutel orl chronicl pain -impairedl peripherall tissuel perfusion -impairedl mobility
Q:l implementation:l skinl integrityl andl woundl care
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Answer:
HEALTHl PROMOTION
1.l nutrition:
-highl protein,l cals,l nutrients 2.l preventl pressurel injuries -topicall skinl carel andl incontinencel managementl >cleanl skinl withl waterl andl nonionicl surfactant,l dry,l applyl moisturizer >control/containl incontinence,l perfusions,l drainage.l whenl incontinencel episodel occurs,l clean,l dry,l moisturize -positioning >repositionl tol reducel andl relievel pressurel onl thel skinl andl tol limitl timel tissuel isl exposedl tol pressure.l 30l degreel laterall positionl recommendedl tol avoidl bonyl prominences.l frequencyl isl basedl offl clientl assessment
-supportl surfaces:l
>specializedl devicesl likel mattressl overlays,l mattressl replacements,l seatl cushions,l andl seatl cushionl overlays.l designedl tol redistributel pressure,l managel tissuel loads,l shearl andl microclimate -assessl forl pressurel injuries:l acutel (withinl 8l hrs),l longl term,l critical,l homel (uponl admission) FIRSTl AIDEl FORl WOUND -whenl asl woundl occursl stabilizel cardiopulmonaryl function,l stopl bleeding,l cleanl thel wound,l andl protectl it 1.l hemostasis:l applyl pressurel tol stopl bleeding,l whenl bleedingl hasl stoppedl applyl al dressingl tol keepl thel edgesl closedl andl tol allowl al bloodl clotl tol form.l pressurel dressingsl arel commonl inl firstl 2l days 2.l cleaning:l usel normall salinel andl gentlel mechanicall cleaning,l thenl dressl withl moistl salinel dressing 3.l protect:l byl applyingl cleanl moistl dressingl (tol keepl microl ol out)l andl immobilizingl thatl partl ofl thel body
>primaryl intention:l canl takel dressingsl offl whenl drainagel stops
>secondaryl intention:l keepl dressingsl onl bcl theyl keepl woundl moistl
WOUNDl MANAGEMENT 1.l education:l canl usel videotapesl orl writtenl materialsl tol helpl teachl patients/familiesl abtl howl tol preventl andl carel forl pressurel ulcersl andl wounds 2.l nutrition:l earlyl nutritionall assessmentl (JCl saysl withinl firstl 24l hrsl ofl admission)l andl interventionl isl imperativel forl healing.l needl morel proteinl (1.8l g/kg/day)l forl epidermall tis
Q:l implementl pt.l 2
Answer:
DRESSINGS
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