Exam 2: NSG122/ NSG 122 (Latest 2024/ 2025 Update) Nursing Fundamental Concepts Exam Review| Questions and Verified Answers| 100% Correct| Grade A- Herzing

Exam 2: NSG122/ NSG 122 (Latest 2024/ 2025 Update) Nursing Fundamental Concepts Exam Review| Questions and Verified Answers| 100% Correct| Grade A- Herzing Q: 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 Q: Signs of a healthy wound Answer: Edges of a healthy healing surgical wound appear clean and well approximated w/ crust along wound edges. Q: Signs that a wound is not healing Answer: Edges are not approximated and they can become separated. Q: 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 Q: 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 Q: What stage of pressure injury: full thickness tissue loss w/ exposed tendon or muscle Answer: Stage 4 Q: What stage of pressure injury: intact skin w/ non-blanchable redness of localized area over bony prominence Answer: Stage 1 Q: Which stage of pressure injury is unstageable? Answer: Stage 5 Q: Sanguineous drainage Answer: consists of large #9s of RBCs and looks like blood o Bright-red sanguineous drainage is indicative of fresh bleeding o Darker drainage indicates older bleeding Q: Serosanguineous drainage Answer: mixture of serum and RBCs; light pink to blood-tinged Q: Serous drainage Answer: composed primarily of clear, serous portion of blood and from serous membranes; clear and watery Q: Wound Assessment Answer: Inspection for sight and smell Palpation for pain, color, appearance, drainage Q: Labs that indicate the patient is at risk for pressure injury Answer: o Albumin = 3.2 mg/dL (normal 3.4-5.4 mg/dL) o Prealbumin = 15 mg/dL (normal 19-38 mg/dL) o Total lymphocyte = 1,000/mm3 (normal 1,500-4,000/mm3) o Hemoglobin A1c = 6.5% (normal 6%) o Glucose = 126 mg/dL (normal fasting 110 mg/dL) Q: Wound contamination occurs through