Nur 242 Med/surg Exam 1 Review Latest Questions With Complete Grade A Answers

Patient at risk for pressure injury - with wounds {Ans: - remove dressing (noting condition of dressing) - cleanse wound and remove and compare with previous notations of wound condition - presence, amount and nature of exudate - use disposable paper tape measurement to measure wound diameter and depth - amount (%) and type of necrotic tissue - presence of granulation/epithelium - presence or absence of cellulitis presence or absence of odor take patients temperature to assess for fever}Skin cancer prevention {Ans: avoid sun exposure between 11 - 3pm use sunscreens with the appropriate skin protection factor wear a hat, opaque clothing, and sunglasses keep a body map of skin spots, scars, and lesions to detect when changes have occurred}Sequence of inflammation {Ans: Stage 1 - injured tissue and the leukocytes mast cells in this area secrete histamine, serotonin and kinins that constrict the small veins and dilate the arterioles in the area of injury. These changes cause redness and warmth to the tissues Stage 2 - An increased number of circulating neutrophils occurs. Exudate in the form of pus occurs, containing dead WBC's, necrotic tissue, and fluids that escape from the damaged cells. Thus, you will