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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?

Full thickness skin loss with visible adipose tissue.

Full thickness skin loss with visible bone.

Intact skin with localized erythema.

Partial-thickness skin loss with red tissue in the wound bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

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Correct Answer is B

Explanation

Choice A rationale:

Documentation is important but not the first priority.

Choice B rationale:

Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.

Choice C rationale:

Checking the setting on the NPWT unit is important but comes after assessing the patient.

Choice D rationale:

Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.

A. Alginate. B. Dry gauze. C. Hydrogel. D. Transparent.

Correct Answer is A

Explanation

Choice A rationale:

Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.

Choice B rationale:

Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.

Choice C rationale:

Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.

Choice D rationale:

Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.

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A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

Correct Answer is B

Explanation

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

Correct Answer is A

Explanation

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

The nurse places Dakin solution in a wound to accomplish chemical:

A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

The nurse places Dakin solution in a wound to accomplish chemical:

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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?