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NURS 6011 Study Guide Exam 3 2025/2026 Questions with Elaborated Answers (Original Exam) Already A Graded-Marquette University
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normal BP 120/ normal respiratory rate 12 - 20 normal pulse rate 60 - 100 Normal temperature 97.8-99. debridement cleaning away devitalized tissue and foreign matter from a wound
dehiscence separation of layers of a surgical wound; may be partial, superficial or a complete disruption of the surgical wound desiccation dehydration the process of being rendered free from moisture epithelialization stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of ground glass to pink eschar thick, leathery, scar or dry crust that is necrotic and must be removed for adequate healing to occur evisceration protrusion of viscera through an incision
You have a 6th grader who has been getting bad grades lately, rubs their eyes frequently, visual acuity is poor what is the nursing diagnosis? ineffective role performance related to visual impairment in an older adult the skin loses turgor and is more fragile what are some nursing interventions to help with that? maintain hydration and IV fluids as prescribed maintain record of intake and output use caution when removing tape in older adults they experience decreased secretion of enzymes and absorption of nutrients that increase their risk for delayed wound healing what are some nursing interventions to combat this? maintain intake of adequate calories ensure that the diet is high in protein, vitamin A, vitamin C and trace elements monitor lab results such as serum albumin, total protein in older adults if they have a wound the risk for infections increases what are some nursing interventions to combat this?
quantity or odor of exudate type 1 pressure ulcer skin is intact (unbroken) nonblanchable redness swollen tissue darker skin may appear blue/purple type 2 pressure ulcer partial thickness epidermis and dermis no fatty tissue is visible superficial ulcer abrasion or ulcer type 3 pressure ulcer
full thickness skin loss damage to or necrosis of subcut tissue no exposed muscle or bone ulcer extend down to the underlying fascia, but not through it deep crater with or without tunneling type 4 pressure ulcer full thickness tissue loss destruction of tissue damage to muscle and bone deep pockets of infection and tunneling unstageable pressure ulcer when the stage cannot be determined due to eschar or slough covering the visibility of the wound making the depth unknown
how to document when assessing a wound? note the location of the wound (described in relation to the nearest anatomic landmark such as bony prominences) the size of the wound (taken in mm or cm, measuring length, width, and depth assess wound for approx of wound edges (edges meet) and signs of dehiscence or evisceration assess color of wound and surrounding area note presence of drains, tubes, staples and sutures how to determine the size of the wound? draw the shape and describe it measure the length, width, and diameter how to determine the depth of a wound?
moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down mark the point on the swab that is even with the surrounding skin surface remove the swab and measure the depth with a ruler how to determine wound tunneling? determine the direction
What clinical signs would you see if a wound is infected? redness, swelling, warmth What is the best route for administration of epi? IM what is typically a source for a person to have anaphylactic shock? bee sting what does PEERLA stand for? pupils equal, round, reactive to light, and accommodations cranial nerves associated with eye movement? there are 3 know the roman numerals lll-oculomotor IV-trochlear VI-abducens
What is epistaxis? nose bleed What does a stage 2 pressure ulcer look like? partial thickness skin loss with exposed dermis the wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum filled blister adipose or fat is not visible and deeper tissues are not visible granulation tissue, slough, and eschar are not present There is going to be a question regarding priority patient. The patient you always assess first will have which issue? low respiration remember ABC's airway, breathing, circulation airway will always be the priority
they continue to perform the assessment even though they stated their experience pain while performing the exercise how do you test for tactile fremitus? following the sequence for palpation but avoiding the scapula, place the palmar base or ulnar surface of the hand on the patient's chest above the scapula. Ask the patient to say ninety nine vibrations of air in the bonrchial tree are transmitted to the chest wall when the patient speak. Assess for intensity and symmetry of fremitus from one side of the chest to the other at the same level if fremitus is difficult to palpate, ask the patient to speak louder why do you want to assess for tactile fremitus? this assessment is made to evaluate the density of lung tissue conditions that obstruct or block air movement through lung tissue causes a decrease or absence of tactile fremitus What are age spots and how do they present on the hands of older adults?
solar lentigines age or liver spots on the face, hands, forearms, upper chest, or back solar lentigines or liver spots are common and expected skin finding in older adults mottled dyspigmentation areas look like brown little spots What is the structure that is an extension of the soft palate in the mouth which hangs in the posterior midline of the pharynx? uvula the __ is the midline at the inferior border of the soft palate. uvula A patient is admitted to the ER and reports vomiting, nausea for the past few days upon inspection you not their eyes are sunken in and they have a fever what is the priority nursing action? give fluids IV or oral
when you are performing hand grasps and flexion/extension of your feet do you assess bilaterally or unilaterally? always bilaterally and you assess pulses bilaterally What is the best technique to elicit a response when performing a deep tendon reflex assessment? using a reflex hammer and accurately striking the area over the tendon When you are assessing muscle tone and strength what is the correct way to document your findings? bilaterally 5+ on upper and lower extremities Where are medications administered if the order specifies buccal route? inside the cheek What is the recommended procedure for administering a piggyback medication?
