Exam (elaborations)
Nur 185 exam 2 2024/2025
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Nur 185 exam 2Safety - ANS: Prevention of health care errors and the elimination or migration of injury caused by
health care errors
Active errors - ANS: *made by nurses, physicians and technicians
*who are providing care, responding to patient needs at the "sharp end"
Latent errors - ANS: Are organizational and are errors occurring at the "blunt end"
Diagnostic errors - ANS: Delay in diagnosis
Treatment errors - ANS: Wrong dose, error in performance of treatment
Preventive errors - ANS: Failures in prophylactic treatment and inadequate monitoring or follow up
Communication failure - ANS: Lack of communication that leads to harm
Error prevention - ANS: *prevent problems from occurring with confirmation messages
*errors can only be addressed if they are reported
What is the Morse Fall Scale? - ANS: A rapid and simple method of assessing a patient's likelihood of
falling
Stage 1 wound - ANS: *intact skin with non-blanched redness of a localized area usually over a bone
*darkly pigmented skin may not have visible blanching; it's color may differ from the surrounding area
,Stage 2 wound - ANS: *partial thickness loss of dermis presenting as a shallow open ulcer with a red pink
wound bed without slough
*may also present as an intact or open/ruptured serum-filled blister
Stage 3 wound - ANS: *full thickness tissue loss
*subcutaneous fat maybe visible but bone, tendon or muscles are not exposed
*slough maybe present but does not obscure the depth of tissue loss
*may include undermining and tunneling
Stage 4 wound - ANS: *full thickness tissue loss with exposed tendon or muscle
*slough or ex had may be present on some parts of the wound bed
*often includes undermining and tunneling
suspected deep tissue injury - ANS: *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.
*the area may be preceded tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue
Unstageable wound - ANS: *full thickness tissue loss in which the base of the ulcer is covered by yellow,
tan, grey, green or brown and/or Escher (tan brown or black) in the wound bed
What is the Braden Scale? - ANS: an evidence-based tool that looks at various factors that put patients
at risk for developing a pressure ulcer. Includes:
sensory perception
moisture
activity
, mobility
nutrition
friction
shear
How do you assess for change of conditions? - ANS: *check skin (heels, buttocks, elbows, etc)
*vital signs
*assess for resp depression (respirations less then 12, elevated WBC, elevated temp, low or high BP,
ETC)
*change in mental status
*monitor and assess for swallowing
*monitor weight loss and labs
*monitor for urine retention
*monitor IV sites for complications
infiltration - ANS: IV solution leaking outside IV catheter into the surrounding tissue
Phlebitis - ANS: inflammation of a vein
Extravasation - ANS: Vesicant IV med leaking out the IV catheter into the tissue causing severe damage
air embolism - ANS: IV leaking into the vein
Speed shock - ANS: IV medication infusing too fast
Sepsis - ANS: Infection in the blood stream
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