A nurse is assessing a pressure injury with undermining and tunneling. What measurement practice should be followed?
Measure undermining and tunneling separately and record them individually.
Include undermining and tunneling measurements within the wound's depth.
Use a ruler to measure only the wound's length and width.
Estimate the measurements visually.
The Correct Answer is A
A. Measure undermining and tunneling separately and record them individually. Undermining and tunneling are separate, distinct characteristics of a wound that indicate the extent of tissue destruction under the wound edges. They must be measured individually at their deepest/widest point (using the clock face method to note their location) and recorded separately from the wound's overall length, width, and depth. This provides the most accurate assessment of the wound's progression or regression.
B. Include undermining and tunneling measurements within the wound's depth. Undermining and tunneling are measured horizontally under the wound edges (undermining) or in a specific direction away from the wound bed (tunneling). They are separate from the maximum vertical depth of the visible wound bed itself. Combining them would lead to an inaccurate measurement of the wound's true depth and extent.
C. Use a ruler to measure only the wound's length and width. While length and width are essential, failing to measure and record the depth, undermining, and tunneling in a complex wound like a pressure injury would result in an incomplete and insufficient assessment of tissue damage.
D. Estimate the measurements visually. Accurate wound management requires precise, objective measurements to monitor healing progress. Visual estimation is subjective and prone to significant error, which can compromise treatment decisions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sanguineous drainage: Sanguineous drainage is fresh, bright red blood.
B. Serosanguineous drainage: Serosanguineous drainage is a mixture of serous fluid (pale, watery) and sanguineous fluid (blood), resulting in a thin, watery, pale pink or light red color. This is a common, normal finding in the inflammatory and proliferative phases of healing.
C. Purulent drainage: Purulent drainage is thick, opaque, and colored (yellow, green, or brown) with a foul odor, indicative of infection.
D. Serous drainage: Serous drainage is clear, thin, and watery, like plasma. The presence of a pink tint indicates blood, classifying it as serosanguineous.
Correct Answer is B
Explanation
A. Check the patient's blood sugar levels: This is an important step in assessing a diabetic patient whose high blood sugar can impair healing, but it is not the most immediate priority for an actively infected wound.
B. Assess for signs of systemic infection: A foul odor (purulent drainage) indicates a localized infection. The priority is to assess if that infection is spreading systemically (sepsis) by checking for signs like fever, tachycardia, hypotension, and altered mental status. This assessment dictates the urgency of treatment (e.g., blood cultures, IV antibiotics).
C. Measure the wound dimensions: This is a routine, necessary step for wound documentation but is secondary to assessing the patient's immediate physiological status and the risk of life-threatening sepsis.
D. Apply a new dressing over the wound: This is an expected intervention but is secondary to a thorough assessment for systemic involvement, which guides immediate medical interventions.
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