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NU 203 Test 3 Questions with All Correct Answers

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NU 203 Test 3 Questions with All Correct Answers Formation of Pressure Injuries - Answer- 1. Pressure: cause decrease waste product build up and blood flow 2. Ischemia: no oxygen 3. Necrosis: tissue death tissue intolerance - Answer- ability of tissue to endure pressure --> Normal rea...

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  • September 27, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • nu 203
  • nu 203 test 3
  • NU 203
  • NU 203
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NU 203 Test 3 Questions with All
Correct Answers

Formation of Pressure Injuries - Answer- 1. Pressure: cause decrease waste product
build up and blood flow
2. Ischemia: no oxygen
3. Necrosis: tissue death

tissue intolerance - Answer- ability of tissue to endure pressure
--> Normal reactive hyperemia: turns white and then red again
--> non-blanching erythema: doesn't turn white

Low pressure over a prolonged period and high pressure over short period - Answer-
still cause pressure uclers

Age-related - Answer- - skin changes
- polypharmcy
- decrease inflammatory response
- malnutrition

Pressure Injury Sites - Answer- bony prominences:

sacrum
greater trochanter: ball of hip
ischial tuberosity
lateral malleolus outside of ankle
tuberosity of calcaneus
olecranon: elbows

tunneling wound - Answer- channel or pathway that extends in any direction from the
wound through subcutaneous tissue

underming - Answer- tissue destruction of underlying intact skin along the wound
margins

slough - Answer- dead, non-viable tissue - yellow, green or gray lighter, thin, wet,
stringy

eschar - Answer- dead, non-viable tissue- darker, thicker, harder

granulation tissue - Answer- live viable beefy-red, trying to grow new tissue to replace
old tissue

, Epithetial tissue - Answer- live viable tissue - deep, pink healing

Assess color of Injury - Answer- Black
Red
Green: infection
White: Ischemia

Maceration (periwound) - Answer- indicates presence of moisture

Erythema (periwound) - Answer- redness (could indicate infection)

Cyanosis (periwound) - Answer- lack of oxygen; poor flow or trauma; blue, dusty, purple
color

stage 1 pressure injury - Answer- non-blanchable erythema of intact skin may see
edema, pain
Darkly pigmented skin may not have visible blanching

stage 2 pressure injury - Answer- *partial thickness skin loss with exposed dermis.
*the wound bed is pink or red and moist, may appear as an intact or ruptured blister.

stage 3 pressure injury - Answer- Full-thickness skin loss (adipose visible); may have
edible (rolled edges) possible slough, eschar, undermining or tunneling

stage 4 pressure injury - Answer- Full-thickness skin and tissue loss (muscle/bone
visible)
Often include epibole, undermining, and tunneling
May include slough

Unstageable/Unclassified (pressure injury) - Answer- full-thickness/tissue loss, unknown
depth, base of wound, when the wound base cannot be visualized d/t slough and
eschar

suspected deep tissue injury - Answer- Depth unknown, purple, or maroon area of intact
skin or blood-filled blister

debridement - Answer- removal of dead non-viable tissue

mechanical debridement - Answer- wet to dry dressing soaked in saline to pull out
tissue never used in granulated wounds (scrubbing)

autolytic debridement - Answer- plastic dressing

chemical debridement - Answer- topical enzymes, dakins solution, maggots

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