exam 2 priority questions

What is healing by primary intention?

Wound edges are approximated (closed), with minimal tissue loss and minimal scarring.

sutures and staples

What is healing by secondary intention?

Wound edges cannot be approximated. The wound heals from the inside out, with longer healing time, greater scarring, and increased infection risk.

no sutures/staples

Why does decreased hemoglobin delay wound healing?

It reduces oxygen delivery to healing tissue.

What does a low albumin level indicate in a patient with a wound?

Poor nutrition and reduced ability to rebuild cells.

What are five complications of wound healing?

Hemorrhage, hematoma, infection, dehiscence, and evisceration.

What is the difference between dehiscence and evisceration?

Dehiscence: separation of wound layers(surgical wound opening at suture).

Evisceration: protrusion of visceral organs through the wound opening.

What is the difference between pressure, friction, and shear?

Pressure: downward force.

Friction: skin rubs against a surface.

Shear: skin stays in place while underlying structures slide.

What six categories are assessed using the Braden Scale?

Sensory perception,

moisture,

activity,

mobility,

nutrition

friction/shear.

How often should the Braden Scale assessment be performed according to the lecture?

At least every shift

What Braden Scale score indicates pressure injury risk?

A score of 18 or lower. Lower scores indicate higher risk

What defines a Stage 1 pressure injury?

Intact skin with non-blanchable erythema (redness).

What defines a Stage 2 pressure injury?

Partial-thickness skin loss; a shallow ulcer or intact/ruptured blister.

What defines a Stage 3 pressure injury?

Full-thickness skin loss extending into subcutaneous tissue. Fat may be visible, but muscle, tendon, and bone are not.

What defines a Stage 4 pressure injury?

Full-thickness tissue loss reaching muscle, bone, tendons, or ligaments.

Should stable, dry eschar on the heel be removed?

No. Stable, dry heel eschar should not be softened or removed.

What head-of-bed position helps prevent pressure injuries?

Maintain the head of the bed at 30° or less.

What are common pressure injury sites in a patient lying supine?

Occiput, scapulae, elbows, sacrum, and heels.

What are common pressure injury sites in a side-lying patient?

Ear, shoulder, hip (trochanter), knees, and ankles

What should the nurse assess and document about a wound drain?

Drain type, placement, drainage character, and collection device.

What seven wound dressing categories are identified in the lecture?

Gauze: absorb wounds, cover, secure dressings

transparent film: protect wounds with minor drainage

hydrocolloid: absorbed moisture, turns to gel

hydrogel: debridemain, maintain moist environment

foam: cushion and absorbtion

alginate: high exudate, seaweed based

composite: multiple functions, absorption, protection, and a moist healing environment

What three factors determine which wound dressing should be selected?

Wound stage, tissue type, and treatment goal.

What is the purpose of maintaining a moist wound environment?

To support epithelialization and promote healing.

What are Montgomery ties used for?

Securing dressings while avoiding repeated tape removal on sensitive skin.

What should the nurse do before beginning a sterile dressing change?

verify the order, identify the patient, explain the procedure, provide privacy, assess pain, perform hand hygiene, and prepare supplies.

What is the correct technique for removing an old wound dressing?

Wear appropriate clean gloves,

gently remove the dressing,

assess drainage,

discard soiled materials,

remove gloves,

perform hand hygiene before sterile wound care.

What should the nurse document after a sterile dressing change?

Wound appearance, drainage, cleansing and dressing performed, patient tolerance, and any abnormal findings or interventions.

What should a nurse do if a medication order appears incorrect or unsafe?

Withhold the medication and clarify the order with the prescriber before administration.

What are high-alert medications, and what does PINCH stand for?

Medications with an increased risk of serious harm if used incorrectly.

PINCH = Potassium (IV), Insulin, Narcotics, Chemotherapeutics, and Heparin/other anticoagulants.

What are the seven essential components of a MEDICATION ORDER?

Patient name,

date/time,

medication name,

dosage,

route,

frequency,

prescriber's signature.

What is a PRN medication order?

A medication administered as needed for a specific indication, such as pain or nausea.

What is the difference between a standing order and a one-time order?

Standing = administered routinely until discontinued or changed.

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One-time = administered once.

What do PO, SL, and PR mean?

PO = by mouth.

SL = sublingual (under the tongue).

PR = rectal.

What do IM, IV, ID, and SQ mean?

IM = intramuscular. 90

IV = intravenous.

ID = intradermal. 5-15

SQ = subcutaneous. 45-90

What do BID, TID, QID, and q4h mean?

BID = twice daily.

TID = three times daily.

QID = four times daily.

q4h = every 4 hours.

Which medication abbreviations should nurses avoid because they can cause medication errors?

U (units),

IU (international units),

QD (daily),

QOD (every other day),

trailing zeros (1.0 mg vs 1mg).

What are the six rights of medication administration?

Right patient,

time

route

drug,

dose

documentation.

right to refuse

What is the right patient, and how does the nurse verify it?

Verify the patient's identity using two approved identifiers, such as full name and date of birth, and compare them with the MAR.

what is the right medication/drug?

Verify that the medication label matches the prescribed medication on the MAR.

What is the right dose?

Verify that the prescribed dosage is correct and that medication calculations are accurate before administration.

What is the right route?

Administer the medication using the route specified in the medication order. (PO,IM, etc)

What is the right time?

Administer the medication at the prescribed time and frequency, following medication-specific timing requirements.

What is the right documentation?

Document the medication, dose, route, time, and relevant patient response after administration.

When should the nurse perform the three medication label checks?

When removing the medication from storage,

when preparing it

before administration.

What should the nurse do if a patient reports an allergy to a prescribed medication?

Withhold the medication, assess the reported reaction, and clarify the order with the prescriber.

What should the nurse assess before administering an antihypertensive medication?

Blood pressure, heart rate when indicated, and symptoms of hypotension.

What should the nurse assess before administering insulin?

Blood glucose level, prescribed insulin type and dose, and meal availability when applicable.

What should the nurse assess before administering an opioid pain medication?

Pain level, respiratory rate, sedation level, and blood pressure.

What should the nurse assess before administering an oral medication?

Ability to swallow safely, level of consciousness, aspiration risk, and any NPO restrictions

What are the correct angles for intradermal, subcutaneous, and intramuscular injections?

Intradermal = 5–15°. Subcutaneous = 45° or 90°. Intramuscular = 90°.

What is the maximum subcutaneous injection volume specified in the lecture?

1 mL.

What are the maximum IM injection volumes for the deltoid and ventrogluteal sites according to the lecture?

Deltoid = 1 mL.

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Ventrogluteal = 3 mL.

A nurse reviews the following medication order:

"Metoprolol 25 mg PO twice daily."

Which essential component is missing from this order as written?

A. Medication dosage.

B. Route of administration.

C. Frequency of administration.

D. Prescriber's signature.

Correct Answer: D

Rationale: The order includes the medication name, dose, route, and frequency but does not include the prescriber's signature. A complete medication order must also include the patient's name and the date and time the order was written.

What occurs during the diagnosis phase of the nursing process(ADPIE)?

analyze assessment data and uses diagnostic reasoning to identify patient problems.

CREATE DIAGNOSIS WITH PATIENT DATA

• ex:“Ineffective airway clearance” (nursing diagnosis) vs. “Pneumonia” (medical diagnosis).

After collecting assessment data, the nurse organizes the patient's cues, generates possible diagnoses, and compares the cues with the possible diagnoses. Which phase of the nursing process is occurring?

A. Assessment
B. Diagnosis
C. Planning
D. Evaluation

Correct Answer: B

Rationale: During Diagnosis/Analysis, the nurse analyzes assessment data and uses diagnostic reasoning to identify patient problems. This includes organizing cues, generating possible diagnoses, comparing cues, collecting focused data, and validating diagnoses.

What occurs during the planning phase of ADPIE?

The nurse establishes expected outcomes, and develops a patient-centered plan of care.

• your plan to help patient

• ex: Patient will ambulate 50 feet with assistance within 24 hours.”

What occurs during Evaluate Outcomes?

Compare the patient's observed outcomes with expected outcomes to determine the effectiveness of interventions.

did the plan work to help patient?

ex:: Reassessing pain after analgesic administration.

What are the five steps of diagnostic reasoning?

1. Organize cues

2. generate possible diagnoses

3. compare cues with diagnose

4. collect focused data

5. validate diagnoses.

What occurs during the implementation phase?

The nurse initiates the care plan, evaluates the patient's response, and documents care.

• plan takes action

What occurs during the assessment phase?

collect subjective and objective data to evaluate the patient's health status.

What occurs during the evaluation phase?

nurse determines if expectations were met, considering positive and unintended or negative consequences.

ex: Reassessing pain after analgesic administration. Did it work to reduce pain or no?

Which statement is the best example of an expected outcome developed during the planning phase?

A. "The nurse will encourage the patient to ambulate."
B. "The patient should try to walk more frequently."
C. "The patient will ambulate 50 feet with assistance within 24 hours."
D. "The nurse will assess the patient's ability to walk."

Correct Answer: C

Rationale: Expected outcomes should be measurable, realistic, patient-focused, prioritized, and documented. "Patient will ambulate 50 feet with assistance within 24 hours" provides a specific behavior, distance, and time frame.

What does SBAR stand for when communicating with healthcare providers?

S – Situation: Current patient problem.

B – Background: Relevant patient history.

A – Assessment: Current assessment findings.

R – Recommendation: Recommended action or intervention.

What information belongs in the Recommendation component of SBAR?

The action or intervention being recommended for the patient.

• ex: i recommend you see the patient

hat information belongs in the Assessment component of SBAR?

Current assessment findings and relevant clinical data, such as vital signs.

What information belongs in the Background component of SBAR?

Relevant patient history and clinical information related to the current problem.

What is therapeutic communication?

Patient-directed communication that promotes understanding and builds trust

A nurse contacts a healthcare provider using SBAR. What information should the nurse include in the Assessment and Recommendation sections?

Assessment: Current clinical findings, such as vital signs and patient symptoms.

Recommendation: The action or intervention the nurse recommends for the patient.

What information belongs in the Situation component of SBAR?

The patient's current problem or reason for contacting the healthcare provider.

What does S.O.L.E.R. stand for in therapeutic communication?

S – Sit squarely (face the person)

O – Open posture

L – Lean in

E – Eye contact

R – Relax

What is expressive aphasia?

Inability to formulate and/or send a message.

what in an alginate dressing and what do you use it for?

derived from seaweed and absorb high exudate

• DO NOT USE FOR DRY WOUNDS

what is approximation?

bringing edges of wound together

what is a foam dressing and what is it used for?

absorbent and protect wounds, good for bony prominences

what is a hydrogel dressing and what is it used for?

similar to alginate by absorbing high exudate. Used for necrosis, infection, and moist healing environment

what is a hydrocolloid dressing and what is it used for?

used for non infected wounds to create moist environment. DO NOT USE FOR INFECTED WOUNDS

what is a transparent film dressing and what is it used for?

thin plastic that allows 02 exchange. used for superficial wounds with no drainage

what bandage is used for a level 1 pressure injury?

transparent film dressing, protect from friction sheer

what bandage is used for a level 2 pressure injury?

a hydrocolloid dressing created a mnoist environment to protect from partial thickness erosion

what bandage is used for a stage 3, 4, and unstageable pressure injury?

an alginate dressing is used for heavy exudate for deep tissue loss and debridement

what bandage should you use for high exudate/drainage?

Foam or alginate

what bandage should be used for dry/minimal drainage?

hydrogel to add moisture

what bandage should be used for moderate drainage?

hydrocolloid or foam to retain moisture while draining

what bandage should be used for minor exudate and superficial wounds?

transparent film