A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?
Deep Tissue Injury
Stage III Pressure Ulcer
Unstageable Ulcer
Stage IV Pressure Ulcer
The Correct Answer is A
Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: While dietary fiber is important for bowel health, raw vegetables can be harder to digest. Cooking or steaming vegetables may be a more suitable option for some individuals with constipation.
Choice B rationale: Limiting activity can contribute to constipation, as physical activity helps stimulate bowel movements.
Choice C rationale: Drinking four to five glasses of water daily is important for maintaining hydration and supporting normal bowel function. Dehydration can contribute to constipation.
Choice D rationale: Bearing down hard when defecating may increase the risk of complications and is not a recommended strategy for relieving constipation.
Correct Answer is A
Explanation
Choice A rationale: Dark amber, cloudy, and unpleasant-smelling urine may indicate a urinary tract infection.
Choice B rationale: Urinary retention is not typically associated with dark amber, cloudy urine.
Choice C rationale: Cloudy urine may be associated with urinary incontinence but is not typically dark amber with an unpleasant odor.
Choice D rationale: Urinary frequency does not typically cause dark amber, cloudy urine.
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