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NUR155 Exam 3 Questions and Correct Answers
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NUR155 Exam 3 Questions and Correct Answers
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NUR155 Exam 3 Questions and Correct AnswersWhat is a Circular Turn Bandage?
✓ ~~~ used to anchor bandages and to terminate them. usually are not
applies directly over a wound because of the discomfort the bandage
would cause
what is a spiral turn bandage?
✓ ~~~ used to bandage parts of the body that are fairly uniform in
circumference.
What is a binder used for?
✓ ~~~ used to support large areas of the body, such as the abdomen or
chest. helps to prevent dehiscent
Pressure Ulcer stage I
✓ ~~~ nonblanchable erythema signaling potential ulceration.
Pressure Ulcer Stage 2
✓ ~~~ partial thickness skin loss (abrasion, blister, or shallow crater)
involving the epidermis and possibly the dermis
Pressure Ulcer Stage 3
✓ ~~~ Full thickness skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia. the ulcer presents clinically as a deep crater with or
without undermining of adjacent tissue.
Pressure ulcer stage 4
✓ ~~~ full thickness skin loss with tissue necrosis or damage to muscle,
bone, or supporting structures, such as tendons or joint capsule.
undermining and sinus tracts may be present
Pressure ulcer stage unstagable
✓ ~~~ full thickness skin or tissue loss. depth is unknown. actual depth of
the ulcer is completely obscured by slough (yellow, tan, gray, green, or
brown) and or eschar (brown, tan, black) in the wound bed
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.
What is stage 1 ulcer treatment?
✓ ~~~ relieve pressure by frequent turning
keep the client dry, clean, and well nourished and hydrated
what is stage 2 ulcer treatment?
, ✓ ~~~ maintain a moist healing environment (saline or occlusive
dressing) apply hyocolloid dressing
promote natural healing while preventing the formation of scar tissues
administer analgesics
provide nutritional supplements
what is stage 3 ulcer treatment?
✓ ~~~ clean and debride the following:
prescribed dressing, surgical intervention, and proteolytic enzymes
administer antimicrobials (topical or systemic)
what is stage 4 ulcer treatment?
✓ ~~~ perform non adherent dressing changes every 12 hr
treatment can be skin grafts or specialized therapy such as hyperbaric oxygen
same as rest of stages
what is wound exudate?
✓ ~~~ material such as fluid and cells, that has escaped from blood
vessels during the inflammatory process and is deposited in tissue or
on tissue surfaces
what is serous exudate?
✓ ~~~ clear watery fluid from plasma
ex. fluid in blister from a burn
what is purulent exudate?
✓ ~~~ thicker than serous exudate because of the presence of pus, which
consists of leukocytes, liquified dead tissue debris, and dead and living
bacteria.
what is the process of pus formation called?
✓ ~~~ suppuration. may be blue, green, or yellow. the color may depend
on the causative organism
what is sangineous exudate?
✓ ~~~ usually indicated bleeding and is bright red
seen in open wounds
what is primary intention healing
✓ ~~~ tissue surfaces approximated (closed), minimal to tissue loss; it is
characterized by the formation of minimal granulation tissue and
scarring
what is secondary intention healing
✓ ~~~ a wound that is extensive and involves considerable tissue loss,
and in which the edges cannot or should not be approximated.
secondary healing differs from primary in what 3 ways?
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