A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

Deep Tissue Injury

Stage III Pressure Ulcer

Unstageable Pressure Ulcer

Stage II Pressure Ulcer

Answer and Explanation

The Correct Answer is C

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

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Correct Answer is C

Explanation

A. Have the nurse wear an N95 respirator during transport. While the nurse should wear an N95 respirator when providing direct care to a patient with TB in a hospital room, the focus during transport is on preventing airborne transmission from the patient to others.

B. Use a standard wheelchair with no additional precautions. Standard precautions are not sufficient for airborne diseases like TB. Without proper precautions, the patient may spread Mycobacterium tuberculosis to others during transport.

C. Have the patient wear a surgical mask during transport. A surgical mask on the patient helps contain respiratory droplets and prevents the spread of TB during transport. This is the standard precaution for transporting patients with airborne infections.

D. Place the patient in a negative-pressure isolation room during transport. Negative-pressure isolation rooms are used for patients while they are in the hospital room, not during transport. Negative pressure cannot be maintained in an open environment.

A. Infection B. Paralytic ileus C. Airway obstruction D. Fluid imbalance

Correct Answer is C

Explanation

A. Infection. Infection is a major concern in burn patients due to loss of skin integrity, but airway compromise is the most immediate life-threatening risk.

B. Paralytic ileus. Burn patients may develop paralytic ileus due to stress response and fluid shifts, but this is not the highest priority compared to airway obstruction.

C. Airway obstruction. Burns involving the face, neck, and chest increase the risk of airway swelling and obstruction. The nurse should assess for signs of respiratory distress, stridor, or hoarseness and be prepared for early intubation if needed.

D. Fluid imbalance. Fluid shifts can cause hypovolemia and shock, making fluid resuscitation critical. However, airway management remains the highest priority, especially in burns affecting the upper airway.

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A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transport a patient with active tuberculosis (TB) to another department for a diagnostic procedure. Which of the following infection control precautions should the nurse implement?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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