NU 203 Test 3 Questions with All Correct Answers
Formation of Pressure Injuries - Answer- 1. Pressure: cause decrease waste product build up and blood flow
2. Ischemia: no oxygen
3. Necrosis: tissue death
tissue intolerance - Answer- ability of tissue to endure pressure
--> Normal rea...
Formation of Pressure Injuries - Answer- 1. Pressure: cause decrease waste product
build up and blood flow
2. Ischemia: no oxygen
3. Necrosis: tissue death
tissue intolerance - Answer- ability of tissue to endure pressure
--> Normal reactive hyperemia: turns white and then red again
--> non-blanching erythema: doesn't turn white
Low pressure over a prolonged period and high pressure over short period - Answer-
still cause pressure uclers
Cyanosis (periwound) - Answer- lack of oxygen; poor flow or trauma; blue, dusty, purple
color
stage 1 pressure injury - Answer- non-blanchable erythema of intact skin may see
edema, pain
Darkly pigmented skin may not have visible blanching
stage 2 pressure injury - Answer- *partial thickness skin loss with exposed dermis.
*the wound bed is pink or red and moist, may appear as an intact or ruptured blister.
stage 3 pressure injury - Answer- Full-thickness skin loss (adipose visible); may have
edible (rolled edges) possible slough, eschar, undermining or tunneling
stage 4 pressure injury - Answer- Full-thickness skin and tissue loss (muscle/bone
visible)
Often include epibole, undermining, and tunneling
May include slough
Unstageable/Unclassified (pressure injury) - Answer- full-thickness/tissue loss, unknown
depth, base of wound, when the wound base cannot be visualized d/t slough and
eschar
suspected deep tissue injury - Answer- Depth unknown, purple, or maroon area of intact
skin or blood-filled blister
debridement - Answer- removal of dead non-viable tissue
mechanical debridement - Answer- wet to dry dressing soaked in saline to pull out
tissue never used in granulated wounds (scrubbing)
autolytic debridement - Answer- plastic dressing
chemical debridement - Answer- topical enzymes, dakins solution, maggots
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