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Question 1

stages of inflamatory response

Answer 1

rapid vasoladation of the area

acumilation of fluid at site of injury

formation of exudate at site of injury

formation of granulation tissue

Question 2

signs of pressure injury in a black people

Answer 2

color remain unchanged when area is pressure is applied

the circumscribed area may warmer or cooler than the surrounding area

skin may differ in firmness either softer or harder

Question 3

what would measure protein deficiency

Answer 3

serum albunim

serum prealbunim

nitrogen balance

Question 5

which nutriotion play a big role in wound healing

Answer 5

zinc

copper

vitamin c

Question 6

avoid ____ _____ ____ when cleaning wound because it may delay wound healing

Answer 6

povidone iodine
hydrogen peroxide
cold irrigation solutions

Question 7

when assessing a wound what should you look for

Answer 7

wound characteristics
outflow of pus
location of wound

Question 8

if a patient come to emergince room withopen wound and evisecerated liver what should you do

Answer 8

assess patient for symptoms of shock

contact surgical team

place sterile towels soaked in saline over the wound

Question 9

wet dressings are a form of

Answer 9

mechanical debridement

Question 10

when should you avoid wet dressings

Answer 10

with a clean granulating wound

Question 11

what do wet dressings do

Answer 11

it removes viable as well as devitalized tissue

Question 12

when caring for a wound a UAP can

Answer 12

observation of changes in skin integrity
changes in dietary intake
measument of the body temp

Question 13

which vitamins would help paitent wound healing

Answer 13

A
C

Question 14

shear injury include

Answer 14

underlying muscle and tissue

Question 15

what are indications of dehisence

Answer 15

popping sensation

increased drainage

Question 16

stage 1 pressure injury charisteristic

Answer 16

localized non blanchable erythema

warm edematous skin

cooler than the adjacent tissue

Question 18

before applying heat therapies the nurse should assess the patient for the presence of which potential contrainications

Answer 18

neuropathies
local abscess
open wound
cardiovascular status

Question 19

if there is a bacterial count of 10^5 per gram of tissue what should you expect

Answer 19

tissue destruction at the site of wound

a delay in colagen synthesis in the wound

thick purulent drainage at the site of wound

Question 20

what is the body fluid with the lowest risk for skin breakdown?

Answer 20

salvia

Question 21

patient has a diabetic ulcer doctor ordered vac therapy for which condition would the nurse assess to prevent therapy complications

Answer 21

fistula

osteomyelitis

Question 22

what are the benefits of bandaging a patient leg wound

Answer 22

promotes venous return
increases hemostatic pressure
decrease blood pooling in the lower extermities

Question 23

the 3 type of people with risk of wound dehiscence

Answer 23

malnourished patient

obese patient

patient with wound infection

Question 24

the three c’s of nutrition

Answer 24

vitamin c
zinc
copper

Question 25

what another word for pus

Answer 25

purulent

Question 26

raising the leg of patient prevents

Answer 26

venous return

Question 27

serosanguineous drainage looks

Answer 27

pink to pale red fluid

Question 28

neutrophils and macrophages do what to the wound

Answer 28

clean

Question 29

braden scale measures

Answer 29

sensory
moisture
activity
mobility
nutrition
friction and shear

Question 30

braden scale sensory

Answer 30

1- completly limited
2-very limited
3- slightly limited
4-no impairment

Question 31

braden scale moisture

Answer 31

1- constantly moist
2- very moist
3- occasionally moist
4- rarely moist

Question 32

braden scale activity

Answer 32

1-bedfast
2-chairfast
3- walks occasionally
4walks frequently

Question 33

braden scale mobility

Answer 33

1- completely immobile
2- very limited
3-slightly limited
4- no limitation

Question 34

braden scale nurtriton

Answer 34

1- very poor
2-probably inadequate
3-adequate
4-excelent

Question 35

braden scale friction and shear

Answer 35

1- problem
2-potential problem
3- no apparent problem

Question 36

Norton scale measure

Answer 36

physical condition
mental state
activity
mobility
contience

Question 37

Norton scale physical condition

Answer 37

4 -good
3-fair
2-poor
1-bad

Question 38

Norton scale mental state

Answer 38

4-alert
3-apathetic
2-confused
1-stupor

Question 39

Norton scale activity

Answer 39

4- fully mobile
3- slightly limited
2-very limited
1-immoble

Question 40

Norton scale contience

Answer 40

4- continent
3- occasional incontenece
2- usual incontinent of urine
1- incontinent of bowel and bladder

Question 41

The PSST assigns a numerical score based on

Answer 41

13 wound attributes

Question 42

the PUSH tool’s score is based on

Answer 42

three characteristics

Question 43

the PUSH tool’s score is based on

Answer 43

wound size, tissue type, and exudate amount