A patient has a stage III pressure ulcer that is draining large amounts of exudate what category of dressing is most appropriate for this wound?
Alginates
Collagen matrix
Tegaderm Absorbent clear Acrylic Dressing
Gauze impregnated w/dry soduim chloride
Alginates
* When applied to a wound, sodium ions in the exudte exchangr w/calcium ions in the dressing, absorbing serous fluid or exudate & forming a nonadhesive, nonocclusive hydrophilic gel that conforms to the wound bed.
Alginates-
are calcium or calcium/sodium salts of alginic acid & are composed of mannuronic & guluronic acids obtained from seaweed.
Did you know that ______ acts as clotting factor (factor IV, this mechanism enables some alginates to function as a hemostat.
calcium
When educating a patient w/a neuropathic foot on the appropriate socks to wear, a provider should not make which of the following statements?
The sock should be fully cushioned w/a nonrestrictive top
The sock should have mended areas and seams over bony prominences
For active patients, socks can be obtained w/silicone over the high-stress areas to prevent shear.
Choos a cotton/acrylic blend to assist in wicking moisture away from the foot.
The sock should have mended areas and seams over bony prominences
* Socks for neuropathic foot should not have any mended areas or seams that lie over bony prominences, this causes increased pressure and will lead to skin breakdown.
When educating a patient w/a neuropathic foot on the appropriate socks to wear, a provider should inform patient of the following statements, as education?
- The sock should be fully cushioned w/a nonrestrictive top
- For active patients, socks can be obtained w/silicone over the high-stress areas to prevent shear.
- Choos a cotton/acrylic blend to assist in wicking moisture away from the foot.
In the context of evidence ranking, how do Randomized Controlled Trials (RCTs) compare to observational studies?
RCTs rank hight due to their control over confound variables
Observational studies rank higher due to their real-world context
Both are considered equally reliable forms of evidence
RCTs rank lower due to limited real-world applicablility
RCTs rank hight due to their control over confound variables
* RCTs rank higher in the evidence hierarchy because they are designed to minimze confounding variables, allowing for clearer conclusions about cause-and-effect relationships between interventions & outcomes.
A compression stocking that provides 25-35 mm Hg of compression is considered to be in what compression class?
Class 1
Class 4
Class 2
Class 3
Class 3
* This class of hose/stockings provide a greaded compression from ankle to below the knee to mobilize edema fluid.
There are 4 classess of compression stockings based on the amount of compression they deliver:
Class 1: 14-19 mm HG
14-19 mm HG
There are 4 classess of compression stockings based on the amount of compression they deliver:
Class 2:
19-24 mm HG
There are 4 classess of compression stockings based on the amount of compression they deliver:
Class 3:
25-35 mm HG
* Debate exists over which class is most effective, the best stockings ar the that patients will actually wear. Literature generally supports 30-40 mm HG compression as a good compromise between therapeutic effect, comfort, and ease of use
There are 4 classess of compression stockings based on the amount of compression they deliver:
Class 4: 10-50 mm HG
40-50 mm HG
According to the American Burn Association's burn injury categories, which criterion defines a moderate burn?
A 30% TBSA burn injury for all patients
Any burn on any patient involving the face, eyes, ears, hands, or perineum
A 10% TBSA burn injury for children & elderly
A 15% to 25% TBSA burn injury for adults
A 15% to 25% TBSA burn injury for adults
*
ABA category of moderate burn:
Adults TBSA is
15 to 25%
ABA category of moderate burn:
Children > 10 years or adults < 40 years. Mixed partial-and-full thickness burns of
10% to 20% TBSA
ABA category of moderate burn:
Full-thickness burns not involving the fac, ears, eyes, hands, feet, or perineum & without functional impairment
< 10%
The ____________ cateroizes burns a minor, moderate, or majoy and has established criteria for burn-center referral. Patients with major-or those meeting specific criteria-require treatment in spcialized burn center
American Burn Association (ABA)
Which legal principle is essential to consider when making culturally sensitive wound care decisions?
Beneficence
Non-maleficence
Autonomy
Justice
Justice
* This principle ensures that all patient receive equitable treatment regardless of cultural background. In wound care, justice requires that no group is favored or disadvantaged & that care delivery respects cultural beliefs & practices.
Which team member is typically responsible for initially identifying a new or deteriorating wound within a hospital setting?
Physical or occupatient therapist
Nursing Assistant
Physician
Registered Nurse
Registered Nurse
* due to their trained assessments
A wound on a pt.s right hip shows red granulation tissue. The wound edges are firm, and soft, and ti contracting into a rectangular shape. Which phase of healing is this wound in?
Maturation
Proliferation
Inflammation
Hemostatsis
Proliferation - 3rd phase in wound healing
* Restoration of skin color & contour symmetry as peri-wound edema resolves. - Formation of red granulation tissue at the peri-wound perimeter. - Active wound contraction & epithelialization leading to scar formation.
Hydrogel dressings should be used for wounds with which of the following levels of exudate?
Highly exudative wounds only
Dry to minimally exudative wounds
Moderate to highly exudative wounds
Minimally to moderatelly exudative wounds
Dry to minimally exudative wounds
When should facial sutures generally be removed?
1 to 3 days
7 to 10 days
14 to 21 days
3 to 5 days
3 to 5 days
Sutures should be removed within ____ to ____ ___ of placement, depending on the anatomic location.
1 to 2 weeks
Suture removal for face:
3 - 5 days
Suture removal for scalp, chest, fingers, hand & lower extremity:
7 - 10 days
Suture removal for back, forarm, and foot:
10 - 14 days
Which of the following is not a physiologic change to the skin that occurs naturally with age?
Decreased sweat glands
Decreased collagen & elastin fibers
Increased fatty layers
Increased time for regeneration
Increased fatty layers
Regarding venous insuffieciency, what is the gold standard in detecting blood flow & possible reflux in outpatient setting?
Venous duplex scanning
Air plethysomgraphy (APG)
Photoplethysmography (PPG)
Ambulatory venous pressure monitoring
Venous duplex scanning
* Also known as Color duplex US scanning.
In the United States, which of the following drugs is most commonly prescribed for venous disease & is an effective adjunct to compression therapy?
Micronized purified flavonoid fraction (MPFF)
Aspirin
Pentoxifylline
Horse chestnut see extract (HCSE)
Pentoxifylline
_________ ____ is an invasive vascular test used to evaluate the function of the calf muscle pump and detect venous hypertension. It is traditionally performed by inserting a needle into a foot vein while the patient performs tiptoe exercises, measuring how effectively the veins empty and refill
Ambulatory venous pressure (AMVP) monitoring
Venous duplex scan
A ____ ____ is a non-invasive, painless ultrasound used to visualize veins, evaluate blood flow, and check for blockages or valve issues. It combines standard imaging to "see" the veins (B-mode) with Doppler technology that listens to and measures blood flow
_________ __ is a simple, non-invasive optical technique used to detect blood volume changes in the microvascular bed of tissue. Commonly applied at the surface of the skin, it serves as the core technology for heart rate tracking and blood oxygen monitoring in modern medical devices and consumer wearables
Photoplethysmography (PPG)
________ __ is a non-invasive diagnostic test that evaluates lower limb blood flow and venous disease. By wrapping an air-filled cuff around the leg to measure volume changes, the procedure accurately quantifies valvular reflux, calf muscle pump function, venous obstruction, and chronic venous insufficiency (CVI)
Air plethysmography (APG)
_______________________ is an oral venoactive drug composed of 90% diosmin and 10% other flavonoids, such as hesperidin. It acts by reducing inflammation, improving lymphatic drainage, and increasing capillary resistance. It is widely used to treat vascular conditions.
Micronized purified flavonoid fraction (MPFF)
Pentoxifylline
A prescription medication used to improve blood flow and relieve leg pain, cramping, or aching (intermittent claudication) caused by peripheral artery disease. It works by decreasing blood viscosity and making red blood cells more flexible, allowing oxygen to reach the muscles more easily
The most commonly seen fistulas involve which areas?
Skin & GI tract
Intestine & colon
Intestine & wound bed ( or wound surface)
Skin & bladder
Skin & GI tract
* Internal fistulas connect two internal organs (example- from small bowel to the bladder) whereas external fistulas involved the skin ( for example, from the small bowel to the skin).
The Sussman Wound Healing Tool (SWHT)
The documentation is simple, and the outcomes are visual
The SWHT is a qualitative tool
It was developed to monitor & track the effectiveness of physical therapy technologies used for pressue ulcer healing.
What common foot lesion is caused by an infection of the human papillomavirus?
Plantar warts
Tinea pedis
Callus
Hard and/or soft corn
Plantar warts
A pt.s lab values reveal increased serum osmolarity & serum creatinine, as well as elevated hematocrit levels. What condition does the most likely indicate?
Fluid overload
Malnutrition
Dehydration
Infection
Dehydration
Signs of dehydration: Weight loss, Dry skin & cracked lips, Poor skin turgor and thirst, Fever or hypothermia, Altered sensation, dizziness, and confusion, loss of appetite & nausea.
Dehydration lab findings:
- Increased serum creatinine & hematocrit
- Elevated BUN, potassium, chloride, and osmolarity (sodium may be high, normal, or low depending on the cause)
- Decreased blood pressure & increased pulse rate (tachycardia)
- Concentrated urine & constipation
Which tissue layer of the skin is the thickest?
Basement membrane
Epidermis
Hypodermis
Dermis
Dermis
* also known as the true skin is the thickest layer of the skin
Impaired skin integrity is an appropriate nursing diagnosis for which stage of pressure ulcer?
Stage IV
Stage III
Stage II
Unstageable pressure injury
Stage II
* This stage applies to ulcers that involve only superficial damage to intact skin or partial-thickness loss.