Wound Staging Exam 2

Question 1

What is the definition of a pressure injury?

Answer 1

Localized injury to the skin and underlying tissue, usually over a bony prominence

Question 2

What scale is used to assess a client’s risk for pressure injuries?

Answer 2

Braden Scale

Question 3

Name a contributing factor that compresses small blood vessels and hinders blood flow.

Answer 3

Pressure

Question 4

What effect does moisture have on the skin in relation to pressure injuries?

Answer 4

Macrates the skin

Question 5

What is shear in the context of pressure injuries?

Answer 5

When one layer of skin slides horizontally over another, compressing tissue

Question 6

List risk factors for pressure injuries.

Answer 6

• Impaired circulation
• Reduced oxygen supply
• Limited mobility or reduction in sensation
  *Poor nutrition, dehydration and
  Advanced age

Question 7

What characterizes Stage 1 of a pressure injury?

Answer 7

Localized area of intact skin with nonblanchable redness

Question 8

What does Stage 2 pressure injury involve?

Answer 8

Partial-thickness loss of dermis, a blister is stage 2

Question 9

What is visible in Stage 3 pressure injuries?

Answer 9

Adipose tissue seen, full thickness loss with damage of subcutaneous tissue.

Question 10

What distinguishes Stage 4 pressure injuries?

Answer 10

Full-thickness skin loss with exposed bone or tendon

Question 11

What is a Deep Tissue Injury (DTI)?

Answer 11

Intact skin that is persistently discolored, purplish or deep red

Question 12

What defines an unstageable pressure injury?

Answer 12

Full-thickness skin loss with base obscured by slough or eschar

Question 13

What are examples of medical devices associated with pressure injuries?

Answer 13

• Feeding tubes
• Intravenous catheters
• Orthopedic devices

Question 14

What are Hospital Acquired Pressure Injuries (HAPIs)?

Answer 14

Pressure injuries that occur during hospitalization

Question 15

What is a mucosal membrane pressure injury?

Answer 15

Injury to a mucous membrane caused by pressure from a foreign device

Question 16

What is the gold standard method for obtaining a wound culture?

Answer 16

Tissue biopsy

Question 17

Name one antiseptic solution that should not be used on healing tissue.

Answer 17

Hydrogen peroxide

Question 18

What is the purpose of normal saline in wound cleaning?

Answer 18

It is safe and will not harm injured or healing tissue

Question 19

Fill in the blank: _______ is isotonic and similar to the body.

Answer 19

Normal saline

Question 20

What are the goals of wound dressing?

Answer 20

• Prevent drying of the wound bed
• Absorb drainage
• Protect from contamination

Question 21

What is a physiological wound environment?

Answer 21

Maintains the right amount of moisture for cells to flourish

Question 22

What is a wet-to-dry dressing?

Answer 22

Coarse gauze moistened with normal saline packed into the wound

Question 23

What is a method of debridement that uses maggots?

Answer 23

Biotherapy

Question 24

What is SANTYL Ointment used for?

Answer 24

Removes dead tissue from wounds for healing

Question 25

What is Algidex Ag+ wound dressing designed to support?

Answer 25

An optimal moist wound environment

Question 26

Friction is?

Answer 26

when skin is moist, fragile, or rubbed against another surface (wrinkled sheets).

Question 27

Interventions for wound care

Answer 27

Question 28

What nutrition is important to give for wound healing?

Answer 28

Protein

Question 29

Blanchable vs nonblanchable?

Answer 29

nonblanchable- no circulation blanchable- color returns- has circulation

Question 30

What is a HAPI

Answer 30

Hospital acquired pressure injury during stay. chronic conditions diabetes are at risk

Question 31

Common injuries come from

Answer 31

incubation and Foley insertions.

Question 32

Wound Culture

Answer 32

done by provider- standard for a tissue biopsy

Question 33

Prevent wound bed from drying out

Question 34

Wet to Dry dressing

Answer 34

NS is packed in towel to wound and removed after drying