NSG300 Exam 2, NSG 300 nursing exam, nursing

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NSG300 Exam 2, NSG 300 nursing exam, nursing questions and answers, clinical nursing exam, intermediate nursing concepts, NSG300 test prep

Which area is MOST important for the nurse to observe for sacral ulcers?

• Distal tips of the toes
• Lower abdominal folds
• Heels and ankles
• Thighs and calves - ANSWER-C.

Rationale:

Pressure ulcers typically occur over bony prominences such as the heels, ankles, back of head, and sacral area

Which criteria does the Braden scale evaluate?

• Skin integrity at bony prominences, including any wounds
• Risk factors that place the patient at risk of pressure injury
• Amount of repositioning that the patient can tolerate
• The factors that place patient at risk for poor wound healing -

ANSWER-B.

Rationale: 1 / 4

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The Braden scale is a widely used tool for risk assessment of pressure injury development and is composed of six subscales

What are the six subscales that are used in the Braden scale? - ANSWER-Moisture Sensory perception Activity Mobility Nutrition Friction/shear

Which terms are used to describe deteriorated skin related to prolonged, unrelieved pressure on a body part? (SELECT ALL

THAT APPLY)

• Skin tag
• Bedsore
• Skin wound
• Pressure sore
• Pressure ulcer
• Decubitus ulcer - ANSWER-B, D, E, F
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Which role does vitamin A play in wound healing?

• Quickens fibroplasia
• Acts as an antioxidant
• Promotes wound closure
• Acts as immune function - ANSWER-C.

Rationale:

-A. D. Protein quickens fibroplasia and helps with immune function -B. Vitamin C acts as an antioxidant

The nurse finds that a wound is in the proliferative phase of healing. Which changes led them to this conclusion? (SELECT

ALL THAT APPLY)

• The wound is filled with granulation tissue
• There is localized redness, edema, warmth, and throbbing
• The wound contracts to reduce the area that requires healing
• There is vasodilation of surrounding capillaries and

exudation of serum

• There is re-epithelialization of the wound surface -

ANSWER-A, C, E 3 / 4

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Rationale:

Granulation is an indication of new cell growth. The wound contracts to reduce the area that requires healing. Epithelial cells resurface wounds

Which findings are characteristic of a stage 3 pressure injury?

(SELECT ALL THAT APPLY)

• Full-thickness skin loss
• Subcutaneous fat may be visible
• The wound presents as an open, serum-filled blister
• There may be a reddish-pink wound bed without slough
• The bone, tendon, and muscle are not exposed - ANSWER-A,

B, E

When assessing a pressure injury, you note that the tissue over the wound is dark, hard, and adherent to the wound edge. Which stage would be applied to this pressure injury?

• Stage 3
• Stage 4
• Unstageable
• Deep tissue injury - ANSWER-C.

Rationale:

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