Exam 2

Question 1

for skin, remember (4 descriptors)

Answer 1

pink, warm, dry, intact

Question 2

risk factors for pressure wounds

Answer 2

impaired sensory perception, impaired mobility, alterations in LOC, shear force (sliding skin, bones and muscles stay put), friction, moisture

Question 3

stage 1 pressure wound

Answer 3

intact skin, nonblanchable redness

Question 4

stage 2 pressure wound

Answer 4

partial-thickness skin loss involving epidermis, dermis, or both

Question 5

stage 3 pressure wound

Answer 5

full-thickness tissue loss with visible fat

Question 6

stage 4 pressure wound

Answer 6

full-thickness tissue loss with exposed bone, muscle, tendon

Question 7

unstageable pressure wound

Answer 7

full-thickness tissue loss in which the depth of the ulcer is completely obscured by slough/eschar

Question 8

deep-tissue injury

Answer 8

purple or maroon localized area of discolored intact skin or a blood filled blister (caused by pressure or shear)

Question 9

scale used for pressure wounds

Answer 9

Braden

Question 10

SKIN interventions acronym:

Answer 10

Surface appropriate
Keep turning
Incontinence management
Nutrition assessed

Question 11

pH body normal range:

Answer 11

7.35-7.45

Question 12

CO2 normal range:

Answer 12

35-45 mmHg

Question 13

HCO3 normal range:

Answer 13

22-26 mEq/L

Question 14

hypoventilation respiratory acidosis causes:

Answer 14

drug overdose, pulmonary edema, chest trauma, neuromuscular disease, airway obstruction, COPD, atelectasis

Question 15

hyperventilation respiratory alkalosis causes:

Answer 15

fever, anxiety, pregnancy, high altitudes, hypoxia, initial stages of pulmonary emboli

Question 16

ROME

Answer 16

respiratory opposite, metabolic equal

Question 17

Metabolic Acidosis causes:

Answer 17

DKA, sepsis, shock, renal failure, severe diarrhea, salicylate OD

Question 18

Metabolic Alkalosis causes:

Answer 18

loss of gastric juices, overuse of antacids, potassium wasting diuretics, severe vomiting, excessive GI suctioning

Question 19

The nurse knows that most nutrients are absorbed in which portion of the digestive tract?

Answer 19

duodenum

Question 20

The nurse would expect the least formed stool to be present in which portion of the digestive tract?

Answer 20

ascending

Question 21

Fecal impactions occur in which portion of the colon?

Answer 21

rectum