NUR 111 Final Exam Review 65 Questions with Complete Solutions
Informed consent must include: - Correct Answer Adequate disclosure by surgeon
Patient understanding before preoperative sedatives Voluntarily given consent What is considered obese? - Correct Answer 20% or more above ideal weight OR a BMI of 30 or more Pressure Ulcer Development - Correct Answer Stage I --> reddened, unblanchable reddened area, "at risk" Stage II --> partial thickness, pink-red wound bed Stage III --> full thickness, adipose tissue Stage IV --> full thickness, exposed bone, tendon, ligaments Unstageable --> eschar covered
Wound healing - Correct Answer Hemostasis:
Immediate platelets, period of brief vasoconstriction and then vasodilation
Inflammation:
- to 6 days
WBC and macrophages enter to clear debris and bring nutrients
Proliferation:
2-3 weeks Fibroblasts granulation tissue is seen
Maturation: 1 / 2
Begins at 3 weeks, months to years collegen/fibroblasts When is it okay to massage and when is it not okay to massage? - Correct Answer Okay to massage: bony prominences that may be at risk for pressure ulcer
NOT okay to massage: legs where thrombosis may occur
Nursing interventions for someone with decreased sense to touch: - Correct Answer Protect skin from temperature extremes Ensure patient is ambulating with assistive devices
Patients with incontinence are at risk for: - Correct Answer Pressure ulcer
Impaired skin integrity --> ineffective tissue perfusion What nutritional element is important for skin integrity? - Correct Answer Protein Which skin layer is free of vasculature? - Correct Answer The epidermis Stage IV pressure ulcer heals by? - Correct Answer full thickness wound repair What lab data is important for skin integrity?and normal ranges?Serum albumin Prealbumin Body weight Lymphocytes Hemoglobin A1C Glucose - Correct Answer Serum albumin 4-6 g/dl
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