A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?
Stage 2
Stage 3
Stage 1
Unstageable
The Correct Answer is D
A. Stage 2: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss, which may present as an open wound or blister. The presence of black eschar indicates that the skin loss is deeper than what is described in Stage 2.
B. Stage 3: A Stage 3 pressure ulcer involves full-thickness skin loss, which may extend into the subcutaneous tissue but does not involve bone or muscle. However, the presence of black eschar suggests that the wound cannot be accurately assessed because the base is not visible.
C. Stage 1: A Stage 1 pressure ulcer is identified by intact skin with non-blanchable redness. Since there is a broken skin and black eschar in this case, it cannot be classified as Stage 1.
D. Unstageable: A wound is considered unstageable when there is full-thickness skin loss and the base of the wound is covered with necrotic tissue (eschar) or slough, making it impossible to determine the depth and true stage of the ulcer. In this scenario, the black eschar covering the base of the wound prevents accurate staging, so the wound is classified as unstageable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Partial assistance required for daily activities: A score lower than 6 indicates some level of dependence or the need for assistance, which does not apply to a score of 6.
B. Complete dependence on others for daily activities: A score of 0 on the Katz Index would reflect complete dependence. A score of 6 indicates full independence.
C. Full independence in performing daily activities: A score of 6 on the Katz Index signifies that the individual can perform all six activities of daily living independently, demonstrating a high level of functional ability.
D. Moderate assistance required for daily activities: A score of 6 indicates total independence. A score of 3 or lower would suggest moderate assistance is required, making this option incorrect.
Correct Answer is A
Explanation
A. Wash the area of the puncture thoroughly with soap and water: The first action the nurse should take after a needlestick injury is to immediately wash the area with soap and water. This is crucial for minimizing the risk of infection and exposure to potentially infectious materials. Prompt cleaning of the puncture site is essential in reducing the risk of transmission of bloodborne pathogens.
B. Notify employee health services: While notifying employee health services is important for follow-up care and evaluation, it should be done after the initial wound care has been performed. Immediate action should focus on cleaning the injury first.
C. Complete an incident report: Completing an incident report is a necessary step for documentation and accountability in the healthcare setting. However, it should be done after the immediate first aid for the needlestick injury has been addressed.
D. Report the incident to the charge nurse: Reporting the incident to the charge nurse is important for ensuring appropriate follow-up and support, but the priority should be to address the injury first. The nurse should take care of the puncture wound before notifying others about the incident.
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