A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

Unintentional closed wound

Intentional closed wound

Intentional open wound

Unintentional open wound

Answer and Explanation

The Correct Answer is D

Choice A rationale: Unintentional closed wounds involve blunt force trauma but do not typically result in jagged edges with muscle tissue visible.
Choice B rationale: Intentional closed wounds are typically surgical incisions and do not present with jagged edges and visible muscle tissue.
Choice C rationale: Intentional open wounds are typically surgical incisions, not the result of a biking accident.
Choice D rationale: Unintentional open wounds result from accidents and can present with jagged edges and visible tissue.

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Correct Answer is A

Explanation

Choice A rationale: If the client's skin becomes red, the heat application should be stopped to prevent burns or skin damage.
Choice B rationale: Heat applications are generally recommended for 20-30 minutes, not at least 40 minutes, to avoid skin damage.
Choice C rationale: Safety pins should not be used to keep the heating pad in place, as they can damage the pad or cause injury to the client.
Choice D rationale: The temperature of the heating pad should be set to a comfortable and safe level, typically below 42.2° C (108° F).

A. Unstageable Ulcer B. Stage II Pressure Ulcer C. Stage IV Pressure Ulcer D. Stage III Pressure Ulcer

Correct Answer is A

Explanation

Choice A rationale: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.

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A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving heat applications using a heating pad. Which of the following actions should the nurse take when applying the pad?

Correct Answer is A

Explanation

A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

Correct Answer is A

Explanation

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

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?

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

The nurse is caring for a patient with a fractured left leg and is using crutches. Which statement indicates the patient has correct understanding of how to properly use her crutches?

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?