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. Question: Signs that a wound is not healing Answer: Edges are not approximated and they can become separated. Ques tion: 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 i njury: full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscles are not exposed Answer: Stage 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:
pink wound bed w/out slough Answer: Stage 2 Question: What stage of pressure i njury: full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscles are not exposed Answer: Stage 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:
