NSG 122 - Nursing Fundamental Concepts
Exam 2
Question:
This scale evaluates:
- Skin integrity at bony prominences, including any wounds
- Risk factors that place pt at risk for skin breakdown
- Amount of repositioning that the pt can tolerate
- Factors that place the pt at risk for poor healing
Answer:
Braden Scale
Question:
Signs of a healthy wound
Answer:
Edges of a healthy healing surgical wound appear clean and well approximated w/ crust along wound edges.
- / 3
Question:
Signs that a wound is not healing
Answer:
Edges are not approximated and they can become separated.
Question:
What stage of pressure injury:
partial thickness loss of dermis presenting as a shallow open ulcer w/ red- pink wound bed w/out slough
Answer:
Stage 2
Question:
What stage of pressure injury:
full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscles are not exposed
Answer:
Stage 3
- / 3
Question:
What stage of pressure injury:
full thickness tissue loss w/ exposed tendon or muscle
Answer:
Stage 4
Question:
What stage of pressure injury:
intact skin w/ non-blanchable redness of localized area over bony prominence
Answer:
Stage 1
Question:
Which stage of pressure injury is unstageable?
Answer:
Stage 5
Question:
Sanguineous drainage
Answer:
- / 3