front 1 Abrasion | back 1 Superficial with little bleeding and is considered a partial-thickness wound |
front 2 Approximated | back 2 To come close together, as in the edges of a wound |
front 3 Blanch Test | back 3 Pressing a finger on the affected area; it turns a lighter color and returns to a normal color. |
front 4 Blanching | back 4 When the normal red tones of the light-skinned patient are absent |
front 5 Blanchable Hyperemia | back 5 Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color |
front 6 Collagen | back 6 A tough, fibrous protein |
front 7 Debridement | back 7 The removal of nonviable, necrotic tissue |
front 8 Dehiscence | back 8 Separation of the edges of a wound, revealing underlying tissues. |
front 9 Dermal-Epidermal Junction | back 9 The membrane that separate the two skin layers |
front 10 Dermis Layers | back 10
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front 11 Drainage Evacuators | back 11 Convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. |
front 12 Epidermis Layers | back 12
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front 13 Epithelialization | back 13 The formation of granulation tissue into an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment. |
front 14 Eschar | back 14 Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed. |
front 15 Evisceration | back 15 Protrusion of visceral organs through a surgical wound. |
front 16 Extravasation | back 16 A discharge or escape, as of blood, from a vessel into the tissues. |
front 17 Exudate | back 17 Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes. |
front 18 Fibrin | back 18 A fibrous, non-globular protein involved in the clotting of blood |
front 19 Fluctuance | back 19 Soft, boggy feeling when tissue is palpated; usually a sign of tissue infection. |
front 20 Friction | back 20 The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens. |
front 21 Granulation tissue | back 21 Red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. |
front 22 Hematoma | back 22 Collection of blood trapped in the tissues of the skin or an organ. |
front 23 Hemorrhage | back 23 Bleeding from a wound site |
front 24 Hemostasis | back 24 Termination of bleeding by mechanical or chemical means or the coagulation process of the body. |
front 25 Hyperemia | back 25 Redness in the skin after the pressure is relieved and blood flow returns. |
front 26 Induration | back 26 Hardening of a tissue, particularly the skin, because of edema or inflammation. |
front 27 Laceration | back 27 Torn, jagged wound. |
front 28 Negative Pressure Wound Therapy | back 28 A therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns. |
front 29 Nonblanchable Erythema | back 29 If the erythematous area does not blanch when you apply pressure, deep tissue damage is probable. |
front 30 Pressure Duration | back 30 Low pressure over a long period of time and high pressure over a short period of time both cause tissue damage. |
front 31 Pressure Intensity | back 31 If pressure is applied and exceeds normal pressure and the vessel is occluded may cause damage. |
front 32 Pressure Ulcer | back 32 Inflammation, sore, or ulcer in the skin over a bony prominence. |
front 33 Primary Intention | back 33 Primary union of the edges of a wound, progressing to complete scar formation without granulation. |
front 34 Puncture | back 34 Wounds bleed in relation to the depth, size, and location of the wound (e.g., a nail puncture does not cause as much bleeding as a knife wound). |
front 35 Purulent | back 35 A yellow, green, or brown color wound drainage. |
front 36 Reactive hyperemia | back 36 The transient increase in organ blood flow that occurs following a brief period of ischemia |
front 37 Sanguineous | back 37 Bright red; indicates active bleeding wound drainage. |
front 38 Secondary intention | back 38 In which the wound is left open and closes naturally (Scar tissue) |
front 39 Serosanguineous | back 39 Pale, pink, watery; mixture of clear and red fluid wound drainage. |
front 40 Serous | back 40 Clear, watery plasma wound drainage |
front 41 Shearing force | back 41 Unaligned forces pushing one part of a body in one specific direction, and another part of the body in the opposite direction. |
front 42 Slough | back 42 Stringy substance attached to wound bed |
front 43 Sutures | back 43 Threads or metal used to sew body tissues together |
front 44 Tissue ischemia | back 44 Point at which tissues receive insufficient oxygen and perfusion |
front 45 Tissue Tolerance | back 45 The ability to endure pressure depends on the integrity of the tissue and the supporting structures. |
front 46 Vacuum-assisted closure (V.A.C.) | back 46 A device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together. |
front 47 Wound | back 47 A disruption of the integrity and function of tissues in the body |
front 48 Category/Stage I | back 48 Intact Skin with nonblanchable redness in a localized area. |
front 49 Category/Stage II | back 49 Partial thickness loss of the dermis and has a shallow, open ulcer. |
front 50 Category/Stage III | back 50 Full thickness skin loss, subcutaneous fat may be visible, and it may include undermining and tunneling; slough may be present. |
front 51 Category/Stage IV | back 51 Full thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present. |
front 52 Unstageable/Unclassified | back 52 Full tissue loss with the depth of the ulcer obscured by slough and/or eschar in the wound bed. |
front 53 Suspected Deep | back 53 Purple or maroon localized area of discolored intact skin or a blood filled blister caused by underlying soft tissue damage. |
front 54 When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? | back 54
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front 55 When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? | back 55
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front 56 What is the correct sequence of steps when performing a wound
irrigation? | back 56
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front 57 For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? | back 57
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front 58 Which of the following describes a hydrocolloid dressing? | back 58
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front 59 What is the removal of devitalized tissue from a wound called? | back 59
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front 60 What does the Braden Scale evaluate? | back 60
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front 61 On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer? | back 61
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front 62 After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) | back 62
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front 63 Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) | back 63
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front 64 Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) | back 64
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front 65 When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) | back 65
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front 66 Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) | back 66
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front 67 Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. | back 67
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front 68 Full thickness skin loss, subcutaneous fat may be visible. May include undermining | back 68
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front 69 Full thickness tissue loss, muscle and bone visible. May include undermining. | back 69
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front 70 Partial thickness skin loss or intact blister with serosanginous fluid | back 70
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