CCBC Nursing 153: Exam 2 with Questions and Correct Answers
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Course
CCBC Nursing
Institution
CCBC Nursing
Skin edges are approximated or CLOSED. This is usually when a patient had surgery and
the wounds were intentionally created in an operating room. - Answer Primary
Intention
Skin layer are NOT close or approximated. This wound is left open until SCAR TISSUE or
granulated tissue forms. If there i...
CCBC Nursing 153: Exam 2 with Questions
and Correct Answers
Skin edges are approximated or CLOSED. This is usually when a patient had surgery and
the wounds were intentionally created in an operating room. - Answer Primary
Intention
Skin layer are NOT close or approximated. This wound is left open until SCAR TISSUE or
granulated tissue forms. If there is a large gaping wound that is being PACKED, the
wound is healing by __________________ ____________________. - Answer Secondary
intention
Healing occurs when a wound is closed at a later time after the wound surfaces have
already started to granulate. This is used when wounds are deep or until there are no
more signs of infection. Whenever a wound is left open for a long period of time TO
DRAIN, the wound is healing by __________________ ____________________. -
Answer Tertiary intention
The wound repair process is different for partial-thickness and full-thickness wounds.
What are the 2 stages of the wound repair process for partial-thickness wounds, such as
a Stage II pressure ulcer? - Answer 1. Inflammatory Response
2. Proliferation (reproduction) and Migration
This is generally limited to the first 24 hours and involves redness, swelling, and a
moderate amount of serous exudate. - Answer Inflammatory Response
Epithelial cells begin to reproduce and migrate across the wound bed soon after the
wound occurs. Wounds left open to the air resurface in 6-7 days. *Wounds kept moist
resurface in only 4 days because epithelial cells migrate better across a moist surface* -
Answer Proliferation (reproduction) and Migration
,The wound repair process is different for partial-thickness and full-thickness wounds.
What are the 4 stages of the wound repair process for full-thickness wounds, such as
Stage III and Stage IV pressure ulcers? - Answer 1. Homeostasis
2. Inflammatory Phase
3. Proliferation (Reproductive) Phase
4. Remodeling (Maturation) Phase
Begins 3 minutes after injury and last up to 3 DAYS. Damaged tissue and mast cells
secrete histamine, resulting in the vasodilation of capillaries and WBC's go to the
damaged tissue. - Answer Inflammatory phase
Begins and lasts 3-24 DAYS. Granulation tissue is produced to fill and resurface the
wound with new skin. - Answer
The body's natural response to trauma. Injured blood vessels constrict, platelets stop
the bleeding, and clots form a fibrin matrix. - Answer
Final stage of the healing process and can take UP TO A YEAR. The collagen scar
continues to gain strength, but the healed wound does not have the strength of the
original tissue. - Answer
The Inflammatory Phase of the wound healing process results in exudate or wound
drainage. Exudate is made up of fluid and cells that escape from the blood vessels and
are deposited in wound drainage. When assessing drainage it's important to note the
,amount, color, consistency, and odor. What would excessive exudate be an indication
of? - Answer The presence of an infection.
What are the 3 functions of wound drainage? - Answer 1. Dilution of Toxins
2. Transportation
3. Removal away from the site
Produced by bacteria and dying cells. - Answer Dilution of Toxins
This includes leukocytes, plasma proteins, and antibodies to the site. - Answer
Transportation
This includes bacterial toxins, dead cells, and debris. - Answer Removal away from the
site
What are the 4 different type of wound drainage? - Answer 1. Serous
2. Serosanguineous
3. Sanguineous
4. Purulent (Pus)
Clear, watery plasma. - Answer Serous
, Drainage is a mixture of serous and some blood tinged, seen with surgical incisions.
Pale, pink, watery mixture of clear and red fluid. - Answer Serosanguineous
Indication of capillary damage; large number of RBC's, severe inflammation. This
drainage is bright red and indicates active bleeding. Will also see clotting. - Answer
Sanguineous
Indication of severe inflammation WITH INFECTION. Contains leukocytes, liquified dead
cells, dead and living bacteria. This drainage is thick, yellow, green, tan or brown. -
Answer Purulent (Pus)
Drains are special equipment that pull drainage away from a surgical area when a
wound has been closed. What are the 3 types of drains? - Answer 1. Jackson-Pratt or J.P.
Drain
2. Hemovac
3. Penrose
Closed suction drainage system that should be emptied when half full. - Answer Jackson-
Pratt or J.P. Drain
Closed suction drainage system. - Answer Hemovac
Drains by GRAVITY. It's a rubber type tube with openings on both ends, allowing the
drainage to accumulate on gauze placed underneath. - Answer Penrose
What are 5 complications of wound healing? - Answer 1. Dehiscence
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