NUR 155 EXAM 3 | FOUNDATIONS OF
NURSING | CORRECTLY ANSWERED
AND GRADED A+ | 2024/2025 GUIDE |
GALEN
What is the Risk Assessment Tool?
- Correct Answer - Braden scale for predicting pressure sore risk.
How does the Braden Scale Work?
- Correct Answer - Total score of 23= Perfect
Anyone below 18= at risk for a pressure ulcer
What stage pressure ulcer is partial thickness loss, abrasion, blister, or
shallow crater, involves epidermis and possible dermis, and is painful?
- Correct Answer - Stage II pressure ulcer
What wound dressing would you use on a Stage II pressure ulcer?
- Correct Answer - Mepaplex or a Duoderm
What stage of pressure ulcer is full thickness loss, damage of necrosis of
subcutaneous, and may extend down to but Not through the fascia?
- Correct Answer - Stage III pressure ulcer
What are tools that you would use for a Stage III pressure ulcer?
,- Correct Answer - Normal saline
Daicins
Wet---> dry dressing
What stage pressure ulcer is full thickness loss with tissue necrosis,
damage to muscle, bone, supporting structures, through the nerves (not
painful), and has tunneling?
- Correct Answer - Stage IV Pressure Ulcer
What kind of tissue is black, leathery, dead tissue that needs to be
debrided for healing to being?
- Correct Answer - Eschar Tissue
What kind of tissue is cheesy, yellowish sometimes white or grey in
color?
- Correct Answer - Slough Tissue
What phase of healing begins immediately and lasts 3-6 days, and
involves homeostasis, phagocytosis, scabs, edema, redness, and
warmth?
- Correct Answer - Inflammatory Phase
What phase of healing begins day 3 or 4 and lasts until day 21 days, and
under the scab there is granulation, regeneration, new blood, scab
dissolves, collagen, granulation tissue, and eschar?
- Correct Answer - Proliferative Phase
,What phase of healing begins day 21 and can last 1-2 years, and has
epithelization/remodeling of the wound, and scars are 80% as strong as
original tissue?
- Correct Answer - Maturation Phase
In exudate (mass of cells and fluid), what is the name of the fluid that
appears to be clear, amber liquid in color and thin and watery?
- Correct Answer - Serous Fluid
In exudate (mass of cells and fluid), what is the name of the fluid that
appears milky or sometimes
- Correct Answer - green, and pus like?
Purulent fluid
- Correct Answer - In exudate (mass of cells and fluid), what is the name
of the fluid that appears as dark blood, deeper in the tissue, and you
should not see this from a superficial standpoint?
Sanguineous Fluid
- Correct Answer - In exudate (mass of cells and fluid), what is the name
of the fluid that appears as bright red/pink thin and watery blood?
In oxygenation, what term is used for very shallow breathing, may lead
to increased levels of C02, or low levels of oxygen, and many COPD
patients may exhibit signs of this?
- Correct Answer - Hypoventilation
In oxygenation, what term is used for very rapid breathing, the rate and
depth of RR increase, and more CO2 is eliminated than is produced?
, - Correct Answer - Hyperventilation
What is the breathing called when a patient is dealing with
hyperventilation that accompanies metabolic acidosis in which the body
attempts to compensate (gives off excess body acids) by blowing off
CO2 through deep and rapid breathing?
- Correct Answer - Kussmaul's breathing
What is the name off condition that is rhythmic waxing and waning of
respirations from very deep--> very shallow and is often associated with
cardia failure, increased intracranial pressure, brain damage and often
times death (DEATH RATTLE)?
- Correct Answer - Cheyne-Stokes respirations
In oxygenation, what is the term for inability to breathe easily unless
sitting up-right or standing (TRIPOD POSITION)?
- Correct Answer - Orthopnea
In oxygenation, what is the term for difficulty breathing or the feeling of
being short of breath
(NOSTRIL FLARING)?
- Correct Answer - Dyspnea
In oxygenation, what is the term for for insufficient oxygen anywhere in
the body?
- Correct Answer - Hypoxia
What are the S/S of Hypoxia?
