NURS 105 Final Exam: Questions &
Answers
What patients are the most at risk for developing pressure ulcers?(Ans- older adults who experienced trauma, spinal cord injuries, fractured hips, have diabetes; patients in long-term homes/community care or critical care settings
List a few elements that cause pressure injuries (Ans- pressure, friction, shearing, impaired sensory perception, impaired mobility, increased moisture
Explain blanching (Ans- occurs when the normal red tones of the light-skinned patient are present
What are the characteristics of a stage one pressure ulcer?
Pg. 1239 for pictures (Ans- intact skin with non-blanchable erythema or dyschromia (darkening); redness
What are the characteristics of a stage two pressure ulcer?
Pg. 1239 for pictures (Ans- partial-thickness injury with visibility to the papillary layer of the dermis
What are the characteristics of a stage three pressure ulcer?
Pg. 1239 for pictures (Ans- destruction of the papillary and reticular layers but not the subcutaneous tissue 1 / 3
What are the characteristics of a stage four pressure ulcer?
Pg. 1239 for pictures (Ans- deep, full-thickness tissue loss with exposed bone, tendon, or muscle
What are the characteristics of a deep tissue pressure ulcer?
Pg. 1239 for pictures (Ans- persistent nonblanchable deep red, maroon, or purple discoloration; can include neurotic tissue and blisters
What are the characteristics of an unstagable pressure ulcer?
Pg. 1239 for pictures (Ans- full-thickness skin and tissue loss obscured by slough or eschar
List a few ways to prevent pressure ulcers (Ans- repositioning at least every two hours, use cushions/protectors, use transfer devices, apply creams, keep bedding and clothing free of folds/wrinkles, improve nutrient intake
Wound classification: Onset and Duration
(Ans- acute= caused by trauma or surgical incisions; wound edges are clean and intact; will be restored quickly
chronic= chronic inflammation or repetitive irritation to wound; impeded healing
Wound classification: Healing Process 2 / 3
(Ans- Primary intention: closed wound
Secondary intention: wound edges are not approximated (closed)
Tertiary intention: wound is left open for several days then edges are
approximated (closed)
Wound drainage: Describe serous, purulent, serosanguineous, and
sanguineous fluid (Ans- Serous~ clear light pink/yellow healing fluid
Purulent~ thick yellow, green, tan, or brown fluid; can be odorous
Serosanguineous~ pale, pink, watery fluid
Sanguineous~ bright red fluid; indicative of active bleeding
How can you detect hemorrhaging?(Ans- by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs and symptoms of hypovolemic shock
Explain the characteristics of different types of tissue: granulation, slough,
eschar (Ans- Granulation~ red, moist tissue Slough~ soft yellow or white tissue; stringy substance attached to wound bed Eschar~ black, brown, tan, or neurotic tissue **must be removed for healing to occur
What needs to be documented after assessing a wound?(Ans- ~type of wound/staging ~dressing type ~blanchable/nonblanchable
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