which is not a reason to perform skin assessments

so the hospital doesn't have to pay for treatment of wounds

phase 1 in post-surgical complications prioritization is

immediate post-operative recovery

which is the presentation of stage 2 pressure ulcers

shallow, open ulcer w/red-pink wound bed; wounds clean/vascular;

a stage 2 pressure ulcer can be described as

partial thickness tissue loss, due to bed sores/decubitus ulcers

mechanical debridement is

wet to dry dressings w/ gauze; insert wet, dry, then remove along w/ tissue

which is not a fact or step in wound irrigation

occlude wound opening w/syringe to intro irrigation fluid into closed space

surgical debridement is

removal of devitalized tissue by scalpel, scissors, other sharp instruments

which is the presentation of stage 4 pressure ulcers

subcutaneous fat may be visible; slough/eschar; undermining/tunneling

a stage 3 pressure ulcer can be described as

pressure related full-thickness tissue loss

which is not considered a abnormal skin assessment finding

skin temperatures is warm and consistent over entire body

pressure ulcers can be caused by all but which

the weight of the person with the pressure injury

a stage 1 pressure ulcer can be described as

pressure related alteration of intact skin usually over bone prominence

which is NOT a part of the presurgical assessment

making sure the vitals received post surgery match pre-surgery don't matter

which is the presentation of stage 1 pressure ulcers

non-blanchable erythema; edema; induration; warm/cool; discolor; itching

a stage 4 pressure ulcer can be described as

pressure related full thickness loss of tissue w/exposed bone/tendon/muscle

which does not describe debridement

does not rid the wound of a source of infection

which is not a fact of nutrition for wound care

they don't need to have a special diet; can have any caloric intake

person who actively assists surgeon by exposing operative area, hemostasis, and possibly suturing afterwards is

registered nurse first assistant

chemical debridement is

santyl topical medication that digests or dissolves the tissue

autolytic debridement is

uses synthetic dressing over wound allow escher to self-digested by enzymes

which is the presentation of stage 3 pressure ulcers

subcutaneous fat may be visible; bone, tendon, muscle not exposed

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fundx4 skin/surgical

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Questions 56

Answers

1
a braden score of 9 or less indicates a low risk of pressure injury development
False
True
2
phase 2 in post-surgical complications prioritization is
post-operative convalescence
recovery in ambulatory surgery
recovery in out patient surgery
immediate post-operative recovery
3
unstageable pressure ulcers have full thickness tissue loss w/actual depth of ulcer obscured by slough or eschar
False
True
4
no/low risk of pressure injury development score is
10-12
13-14
19-23
15-18
5
which is not a reason to perform skin assessments
imperative to determine risk for skin breakdown and guides treatment
so the hospital doesn't have to pay for treatment of wounds
provides an excellent indicator of the state of general health
6
phase 1 in post-surgical complications prioritization is
recovery in out patient surgery
immediate post-operative recovery
recovery in ambulatory surgery
post-operative convalescence
7
which is not considered a abnormal skin assessment finding
tenting of skin and slow return to normal during turgor testing
edema
extremely dry or cracking; fissures present
odorless
8
which is not considered a component of wound care
debridement
cleansing
dressings
letting it fester
9
how many methods of debridement are there
3
1
7
4
10
if you are educating about surgery and patient says they haven't signed consent, you stop immediately and get the doctor
True
False
11
which is the presentation of stage 2 pressure ulcers
non-blanchable erythema; edema; induration; warm/cool; discolor; itching
shallow, open ulcer w/red-pink wound bed; wounds clean/vascular;
subcutaneous fat may be visible; bone, tendon, muscle not exposed
subcutaneous fat may be visible; slough/eschar; undermining/tunneling
12
phase 3 in post-surgical complications prioritization is
recovery in ambulatory surgery
post-operative convalescence
immediate post-operative recovery
recovery in out patient surgery
13
a stage 2 pressure ulcer can be described as
partial thickness tissue loss, due to bed sores/decubitus ulcers
pressure related alteration of intact skin usually over bone prominence
pressure related full-thickness tissue loss
pressure related full thickness loss of tissue w/exposed bone/tendon/muscle
14
person who ensures surgical site/skin antiseptic prep and counts medical instruments, as not to be left inside is
circulating nurse
registered nurse first assistant
scrub tech
scrub nurse
15
which is not considered a normal skin assessment finding
skin temperature is warm and consistent over entire body
elastic skin turgor
skin discoloration
without pruritis
16
mechanical debridement is
santyl topical medication that digests or dissolves the tissue
removal of devitalized tissue by scalpel, scissors, other sharp instruments
wet to dry dressings w/ gauze; insert wet, dry, then remove along w/ tissue
uses synthetic dressing over wound allow escher to self-digested by enzymes
17
which is NOT a part of the SBAR handoff
what happened in surgery, any complications
any particular concerns with post surgery recovery
patient last bowel movement
any issues with anesthesia
18
which is not a fact or step in wound irrigation
irrigation of open wound requires sterile technique
common method of delivering wound-cleansing solution to wound
occlude wound opening w/syringe to intro irrigation fluid into closed space
use a 35ml syringe w/ 19G soft angio cath to deliver the solution
19
only every third patient requires informed consent for a surgical procedure
True
False
20
surgical debridement is
removal of devitalized tissue by scalpel, scissors, other sharp instruments
uses synthetic dressing over wound allow escher to self-digested by enzymes
wet to dry dressings w/ gauze; insert wet, dry, then remove along w/ tissue
santyl topical medication that digests or dissolves the tissue
21
person who maintains sterile technique while draping and handling instruments and supplies is
registered nurse first assistant
circulating nurse
scrub tech
scrub nurse
22
which is the presentation of stage 4 pressure ulcers
shallow, open ulcer w/red-pink wound bed; wounds clean/vascular;
non-blanchable erythema; edema; induration; warm/cool; discolor; itching
subcutaneous fat may be visible; bone, tendon, muscle not exposed
subcutaneous fat may be visible; slough/eschar; undermining/tunneling
23
what is NOT a category of the braden scale
sensory perception
moisture
cleanliness
mobility
24
which is not a cause of pressure ulcers
tissue tolerance
sinus pressure
pressure duration
pressure intensity
25
which is not considered a type of cleansing for wound care
irrigation
debridement
soap and water
anti-septic surgical cleanser
26
which patients should you perform skin assessments on
all of them
older adults
immobile
ambulatory
27
a stage 3 pressure ulcer can be described as
pressure related alteration of intact skin usually over bone prominence
pressure related full-thickness tissue loss
pressure related full thickness loss of tissue w/exposed bone/tendon/muscle
partial thickness tissue loss, due to bed sores/decubitus ulcers
28
which is not considered a abnormal skin assessment finding
skin temperatures is warm and consistent over entire body
skin discoloration (erythema/ bruising)
foul odor
very moist or weeping
29
pressure ulcers can be caused by all but which
the weight of the person with the pressure injury
shear- force exerted parallel to skin
friction- force of two surfaces moving across one another
30
what is NOT a category of the braden scale
friction and shear
activity
nutrition
incontinence
31
high risk of pressure injury development score is
10-12
15-18
13-14
19-23
32
a stage 1 pressure ulcer can be described as
partial thickness tissue loss, due to bed sores/decubitus ulcers
pressure related alteration of intact skin usually over bone prominence
pressure related full thickness loss of tissue w/exposed bone/tendon/muscle
pressure related full-thickness tissue loss
33
which is not a method of debridement
mechanical
non-surgical
autolytic
chemical
34
which is not considered a component of wound care
education
blood sugar 500
hemoglobin
nutritional assessment and supplementation
35
which is NOT a part of the presurgical assessment
get a good surgical history and screen for possible surgery risks
support system, occupation, pain assessment, emotional health
determine patient expectations of surgery and recovery
making sure the vitals received post surgery match pre-surgery don't matter
36
which is NOT a step in post-operative convalescence (phase 3)
planning
implementation
assess
judgement
37
which is not considered a time when a skin assessment should be done
every shift or sooner if patient condition changes
during bath and cleaning after incontinence
don't do it at all
on admission and once shift
38
which is the presentation of stage 1 pressure ulcers
shallow, open ulcer w/red-pink wound bed; wounds clean/vascular;
subcutaneous fat may be visible; slough/eschar; undermining/tunneling
non-blanchable erythema; edema; induration; warm/cool; discolor; itching
subcutaneous fat may be visible; bone, tendon, muscle not exposed
39
a stage 4 pressure ulcer can be described as
pressure related full-thickness tissue loss
pressure related alteration of intact skin usually over bone prominence
partial thickness tissue loss, due to bed sores/decubitus ulcers
pressure related full thickness loss of tissue w/exposed bone/tendon/muscle
40
which does not describe debridement
does not rid the wound of a source of infection
provides a clean base necessary for healing
the removal of nonviable, necrotic tissue
enables visualization of the wound bed
41
what is NOT included in the pre-surgical assessment
plan
implementation
discharge
nursing diagnosis
42
the Braden score is used to predict risk of pressure injuries
True
False
43
which is not a fact of nutrition for wound care
recommended nutritional assessment within 24hrs of admit for pts w/ wounds
pt underweight or losing wgt need enhanced calorie/protein supplementation
they don't need to have a special diet; can have any caloric intake
pt can lose up to 50g of protein/day from open weeping pressure ulcers
44
person who actively assists surgeon by exposing operative area, hemostasis, and possibly suturing afterwards is
scrub tech
circulating nurse
scrub nurse
registered nurse first assistant
45
mild risk of pressure injury development score is
13-14
15-18
10-12
19-23
46
chemical debridement is
wet to dry dressings w/ gauze; insert wet, dry, then remove along w/ tissue
removal of devitalized tissue by scalpel, scissors, other sharp instruments
uses synthetic dressing over wound allow escher to self-digested by enzymes
santyl topical medication that digests or dissolves the tissue
47
autolytic debridement is
santyl topical medication that digests or dissolves the tissue
uses synthetic dressing over wound allow escher to self-digested by enzymes
wet to dry dressings w/ gauze; insert wet, dry, then remove along w/ tissue
removal of devitalized tissue by scalpel, scissors, other sharp instruments
48
moderate risk of pressure injury development score is
19-23
15-18
13-14
10-12
49
the braden score range is
10-25
6-23
0-30
3-29
50
which is not considered a type of cleansing for wound care
sterile water
wound cleanser
sterile saline
Clorox wipes
51
which is the presentation of stage 3 pressure ulcers
subcutaneous fat may be visible; bone, tendon, muscle not exposed
subcutaneous fat may be visible; slough/eschar; undermining/tunneling
shallow, open ulcer w/red-pink wound bed; wounds clean/vascular;
non-blanchable erythema; edema; induration; warm/cool; discolor; itching
52
you are supposed to inspect all skin, especially skin on areas of bony prominences
False
True
53
which is not considered a normal skin assessment finding
foul odor
dry, without cracking or fissures (heel cracks)
no edema
skin color is normal for ethnicity
54
pressure ulcers are localized injury to skin and underlying tissue, usually over a bony prominence
False
True
55
which is not considered a time or person for the braden scale to be performed
on all patients
on admission
only bedridden patients
every shift
56
what is not a part of the skin assessment
be careful- checking skin turgor can cause skin tears in elderly
quality- fragility, color, temperature, moisture, odor, texture, lesions
leaving wraps and dressing intact and not looking at skin underneath
loss of skin integrity- look for skin issues

fundx4 skin/surgical Flashcards | StudBud