Foundations Exam 2
Stage 1 pressure ulcer
intact skin with nonblanchable redness
Slough
lighter in color, thinner and stringy in consistency; color can be yellow, gray, with, green, brown
Dorsal
located near
orthostatic hypotension
low blood pressure that occurs upon standing up
Granulation tissue
new, healthy tissue produced to fill in a wound
Loosely adherent
pulls away from wound, but attached to wound base
How to describe an odor?
strong, foul, pungent, fecal, musty, sweet
orthostatic hypertension
sudden increase in blood pressure when a person stands up
Secondary intention
the wound must heal from the bottom and sides, filling in with new tissue
The nurse is caring for a patient who is taking acetaminophen-hydrocodone for pain following a total knee replacement. Prior to ambulating the patient the nurse will complete each of the following actions. What is priority?
Monitoring the patients vital signs and stability with position changes
Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound?
"My wound will look beefy red within 1 week."
Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.
- Patient who is experiencing shock from a profusely bleeding wound - Patient who just had an incision eviscerate - Patient with a stage 4 pressure injury
Which action would the nurse take when placing noncommercial ice packs on a patient's injured shoulder?
Remove air from the pack before closing.
Using military time, at what time would the nurse turn the patient if the patient was last turned at 1 p.m.?
1500
Which patient situations would prompt the nurse to question a prescription for heat therapy?
A patient with a local tooth abscess A patient with possible appendicitis A patient with bleeding from a small wound
Which action would the nurse take for a mother who calls the clinic reporting that a thick yellowish drainage is leaking out of her daughter's surgical leg incision and the incision edges are red and warm?
Ask the mother to bring her daughter to the office to be evaluated by the surgeon immediately.
The nurse is caring for a patients who is on heparin for prevention of deep vein thrombosis related to immobility. What priority assessment will the nurse complete related to this information?
Assess for abnormal bruising, bloody stools, or pallor
What are the types of wound edges?
Attached or unattached edges, rolled under (edible), macerated, fibrotic, callused
Which treatment is the nurse monitoring when the patient is receiving the slowest type of wound debridement?
Autolytic
Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity?
Bone. Tendon. Muscle.
Which evaluative cue would alert the nurse that a patient with a pressure injury is declining?
Braden Scale score was a 9 but is now an 8.
Which foods would the nurse recommend for a patient with a leg wound who needs to increase vitamin A intake?
Carrots Sweet Potatoes
The nurse is planning can for a patient on bedrest and has a goal of "Patient will maintain an oxygen saturation of 92% or higher during hospitalization." What interventions will help achieve this goal?
Encouraging the patient to cough and deep breathes Turning the patient every 2 hours Elevating the head of the bed to at least 30 degrees Teaching the appropriate use of an incentive spirometer every house while awake
Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?
Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.
Which dressing would the nurse anticipate using for a patient with moderate to excessive amounts of wound drainage?
Foam
Describe the contribution of the musculoskeletal
Form and support Joints - stability and mobility Protection Blood cells & immunity Storage (Ca, Mg, PO4, Protein)
unstageable pressure ulcer
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Stage 4 pressure ulcer
Full-thickness tissue loss with exposed bone, muscle, or tendon
Describe the importance of hygiene in the clinical setting
Hygiene is a way to help prevent the spread of infections.
For which patient hypotheses would the nurse select turning and positioning as a solution?
Impaired Skin Integrity. Risk for Pressure Ulcer/Injury. Impaired Tissue Integrity. Risk for Impaired Skin Integrity.
What are the three stages of healing?
Inflammatory Proliferactive Maturation
Which action for skin hygiene would the nurse take for an obese patient who is immobile?
Keep skin folds dry from perspiration
How to measure a wound?
Length - head to toe direction Width - hip to hip direction Depth - measure deepest part of visible wound bed
Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity?
Low pre-albumin levels. Immobility. Stage 2 pressure injury.
Which actions would the nurse take for a patient receiving negative-pressure wound therapy (NPWT)?
Monitor for granulation tissue in the wound. Avoid using NPWT for a patient with a cancerous wound. If the patient reports pain, change from the black foam to white foam. Report to the health care provider if there is an increase in wound drainage.
Which actions would the nurse take when the patient's wound has increased redness, swelling, induration, and drainage?
Notify the primary health care provider. Take the patient's temperature. Review white blood cell count.
Which actions would the nurse take for a patient receiving heat therapy?
Obtain distilled water for aquathermia treatments. Check on the disoriented patient more frequently. Cover the container and hand when providing warm hand soaks.
Describe the contributions of the cardiopulmonary system
Oxygenation and perfusion Nutrients Waste removal Literally everything
Describe the contribution of the nervous system
PNS vs CNS (Afferent and efferent pathways) PNS: Autonomic and Somatic Left side vs right side Neurotransmitters
Which parameters would the nurse monitor after applying a wrap to an ankle? Correct
Pain. Pallor. Paralysis. Paresthesia. Pulselessness.
Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?
Patient will eat a high-protein diet at every meal. Patient will help with transfers within 24 hours.
Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?
Patient's wound will exhibit granulation tissue in the wound by 1 week.
Which action by the nurse is priority when providing discharge teaching to a patient and spouse about wound care when the spouse is the primary caregiver?
Provide written instructions.
Suspected deep tissue injury
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.
Which action would the nurse take when caring for a patient's Jackson-Pratt drain?
Reactivate the drain after emptying.
Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?
Repositioning the patient. Reporting any changes in patient's skin integrity or condition. Applying a non-sterile dressing for chronic wounds with an established treatment plan.
Which hypothesis would the nurse develop for an immobile patient who has intact skin?
Risk for impaired skin integrity.
Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days?
Therapies consistent with guidelines for treatment of wounds. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN). Agreement of the patient with the treatment plan. Capability of the patient to purchase supplies for home care as required.
Superior
Top, up
Which dressing would the nurse anticipate caring for in a patient who has a noninfected wound with minimal drainage?
Transparent
Which actions would the nurse take for a comatose patient who has frequent liquid stools and has a Braden Scale score of 8?
Turn the patient every 2 hours for Pad and protect any bony prominences. Wash and dry the patient's skin after each liquid stool. Replace soiled
After receiving report, the nurse would delegate which tasks to the unlicensed assistive personnel?
Turning a patient with a pressure injury Cleaning an incontinent patients fo stool and urine
Which techniques would the nurse use to troubleshoot issues with patients' dressings?
Use an abdominal binder to help a patient who has an abdominal wound to cough. Use Montgomery straps for a patient who needs frequent dressing changes. Use a splint to help a patient who has an abdominal incision to deep breathe.
Which action would the nurse take when irrigating a patient's abdominal wound?
Use sterile technique.
What can impart the function of the MSK system?
Weakness Atrophy Contracture Weakened bone structure Joint stiffness
Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?
Wound, ostomy, and continence nurse (WOCN). Social worker. Nutritionist.
Dermis layer of skin
hair follicle layer
Fistula
abnormal connection between two organs or an organ and outside the body
Epithelialization
appear deep pink, progress to pearly pink/light purple from the edges in full thickness wound
If a patient who is day 1 post knee replacement, what would you assess prior to a therapist coming to work on movement?
assess her pain and give any kind of pain medications doctor would like for her to have prior to therapy
Scar tissue
avascular collection of collagen
Distal
away from center
Posterior
back, underside
Granulation tissue
beefy red, granular, bubbly in appearance; red, pink, pale pink, full dusky red
Inferior
below, down
Subcutaneous layer of skin
blood vessel layer
Tunneling
course of pathway that can extend in any direction from the wound. results in dead space
Eschar
darker in color, thicker and hard consistency black or brown in color
Firmly adherent
does not pull away from wound
Snus tact
drainage pathway from a deep focus of acute infection through tissue and/or bone to an opening on the surface
Nonadherent
easily separated from wound base
Epidermis layer of skin
epithelial layer
Anterior
front, top
Stage 3 pressure ulcer
full thickness tissue loss with visible fat
Adipose tissue layer of skin
not good blood flow, fatty layer
Colonized wound
one or more organisms identified on the surface of the wound by culture without overt signs of infection
Dehiscence
partial or complete separation of tissue layers during healing
Stage 2 pressure ulcer
partial thickness skin loss involving epidermis, dermis, or both
Sanguineous
thin, bright red
Serous
thin, watery, clear
Serosanguineous
thin, watery, pale red to pink
Foul purulent
this opaque yellow o green with offensive odor
Undermining
tissue destruction underlying intact skin along wound margins
Evisceration
total separation of tissue layers with protrusion of viscera
Proximal
toward center, nearest
Medial
toward middle
Lateral
toward side
Purulent
which or thin, opaque tan to yellow
Approximation
wound edges that are brought neatly together
Superficial wound
wound involving only the epidermis
Partial-thickness wound
wound involving the epidermis and dermis
Acute wound
wound progresses rapidly through stages of the healing process
Scant
wound tissues moist, no measurable drainage
Closed Wound
wound without an open area on the skin
