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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobilized, but it does not specifically address plantar flexion contractures of the feet.

B. Sheepskin heel pad: While a sheepskin heel pad can help prevent pressure ulcers on the heels, it does not actively prevent plantar flexion contractures. It is more focused on protecting the skin from friction and pressure.

C. Footboard: A footboard is the most appropriate device to prevent plantar flexion contractures. It provides support to the feet and helps keep them in a neutral position, reducing the risk of contractures developing in the calf muscles and Achilles tendon due to prolonged immobility.

D. Abduction pillow: An abduction pillow is used primarily to maintain the position of the legs after hip surgery and to prevent hip dislocation. It does not specifically prevent plantar flexion contractures.

A. Droplet B. Contact C. Protective D. Airborne E. Full semen

Correct Answer is A

Explanation

A. Droplet: Pertussis, also known as whooping cough, is transmitted through respiratory droplets when an infected person coughs or sneezes. Therefore, droplet precautions are necessary to prevent the spread of the infection to others. This includes wearing a surgical mask when within 3 feet of the client and ensuring the client wears a mask when outside of their room.

B. Contact: Contact precautions are used for infections that can be spread through direct or indirect contact with the patient or contaminated surfaces. While there may be some overlap, contact precautions are not the primary focus for pertussis transmission.

C. Protective: Protective precautions (also known as reverse isolation) are utilized to protect immunocompromised patients from infections. This is not applicable for a patient with pertussis, as the focus is on preventing the spread of the infection rather than protecting the patient from pathogens.

D. Airborne: Airborne precautions are used for infections that are transmitted via airborne droplet nuclei, such as tuberculosis or measles. Pertussis does not fall under this category, as it is primarily transmitted through larger respiratory droplets.

E. Full semen: This option is not a recognized type of precaution. The correct term should focus on standard and transmission-based precautions relevant to infectious diseases.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Correct Answer is C

Explanation

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

Correct Answer is A

Explanation

Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?

The nurse is teaching a client who is preparing for surgery. Which teaching about a Jackson-Pratt drain will the nurse include?

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?

The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

In a clinical setting, a patient with a chronic wound is scheduled for debridement. Which of the following is the primary purpose of wound debridement?

When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?