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Galen Nur 155 Exam 3 Questions and Complete Rationales Graded A+
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- GALEN COLLEGE OF NURSING
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- GALEN COLLEGE OF NURSING
Galen Nur 155 Exam 3 Questions and Complete Rationales Graded A+
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Galen Nur 155 Exam 3 Questions andComplete Rationales Graded A+
Types of wounds - Answer: Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
transparent film - Answer: autolytic debridement, semi-permeable allows skin to breathe.
uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears
how do you apply an abdominal binder? - Answer: start at typhoid, fasten from the bottom up
used for support to keep dressing intact
remove every two hours to asses underlying skin and wound
Risk factors for pressure ulcers - Answer: Fecal and unitary incontinence
Friction and shearing
immobility
inadequate nutrition (decreased protein, Vitamin C, zinc)
Decreased mental status
excessive body heat (moisture)
advanced age
chronic conditions
Diminished sensation
Incorrect positioning
Signs of infected pressure ulcer? - Answer: Change in color, odor, or drainage. Sever infections cause
fever and increased WBC.
,During your assessment of a new patient, the nurse notices a Stage I pressure ulcer, what are the signs
that this nurse is correct about this pressure ulcer being a stage one? - Answer: Non-blachable
No opening
What do you do for a stage I pressure ulcer? - Answer: Apply barrier creams
Reposition patient Q2hr
As you assess your new patient you notice a sore on a bony premise that is blister-like, with partial
thickness skin loss, pt is complaining of pain where the wound is present which stage is this pressure
ulcer? - Answer: Stage II
What type of dressing do you use for a stage II pressure ulcer? - Answer: Mepaplex or Duoderm
Full thickness skin loss, involving damage or necrosis of subcutaneous is what stage pressure ulcer? -
Answer: Stage III
Full thickness skin loss with tissue necrosis, damage to the muscle and bone, wound goes through
nerves and not painful with tunneling present, which stage is this wound? - Answer: Stage IV
Treating pressure ulcers - Answer: Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position change
use assistive devices
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
ROM 3reps 2x daily
What is regeneration? - Answer: replacement of destroyed tissue by the same kind of cells
,Primary intention healing - Answer: tissue surfaces are approximated (closed) and there is minimal or no
tissue loss, formation of minimal granulation tissue and scarring
Secondary intention healing - Answer: wound in which the tissue surfaces are not approximated and
there is extensive tissue loss; formation of excessive granulation tissue and scarring and greater risk of
infection
tertiary intention - Answer: Wounds that are left open purposely for 3-5 days to allow edema and
infection to resolve.
serous - Answer: clear, watery plasma
purulent - Answer: containing pus, milky like
sanguineous - Answer: dark bloody drainage
Serosanguineous - Answer: bright red blood
Purosanguineous - Answer: pus in the blood
When should you use heat therapy? - Answer: Vasodilation
Chronic
Increase capillary permeability, cellular metabolism, inflammation
musculoskeletal problems
joint stiffness
arthritis
contractures and back pain
When do you use cold therapy? - Answer: Vasoconstriction
, acute pain
often used for sport injury (sprains, strains, fractures)
decreased capillary permeability, cellular metabolism, inflammation
Factors that affect respiratory function? - Answer: Age
Environment
lifestyle
health status
medications
stress
eupnea - Answer: normal breathing
Tachypnea - Answer: rapid breathing
bradypnea - Answer: slow breathing
apena - Answer: absence of breathing
hypoventilation - Answer: very shallow breathing, may cause increased levels of carbon dioxide. or high
levels of oxygen
Hyperventilation - Answer: very rapid breathing more CO2 is eliminated than provided.
orthopnea - Answer: ability to breathe only in an upright position
Dyspena - Answer: difficulty breathing
Hypoxia - Answer: Low oxygen saturation of the body, not enough oxygen in the blood
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