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.

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Correct Answer is A

Explanation

A. 18: A score of 18 on the Braden Scale indicates that the patient is at low risk for skin breakdown. The Braden Scale scores range from 6 to 23, with lower scores indicating higher risk. A score of 18 or above suggests that the implemented interventions have effectively reduced the risk of skin impairment, making this the best sign that the risk for skin breakdown has been removed.

B. 13: A score of 13 indicates moderate risk for skin breakdown. While this is an improvement from a score of 15, it still shows that the patient remains at risk and requires ongoing monitoring and intervention.

C. 23: A score of 23 indicates very low risk for skin breakdown; however, it is not a feasible score for patients who were initially assessed at 15. Achieving this score would likely suggest an unrealistic improvement in the patient's condition based solely on nursing interventions.

D. 12: A score of 12 indicates a high risk for skin breakdown. This score signifies that the risk has not been effectively addressed, and the patient continues to be vulnerable to skin impairment.

A. Discard the dressing in the bedside trash receptacle. B. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. C. Double-bag the dressing in clear bags and label it "biohazard". D. Dispose of the dressing in a biohazardous waste container.

Correct Answer is D

Explanation

A. Discard the dressing in the bedside trash receptacle: This option is inappropriate because it poses a risk of contamination and infection. Regular trash receptacles are not equipped to handle materials that may be contaminated with blood or infectious waste.

B. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle: While enclosing the dressing in a plastic bag is a step toward containment, discarding it in the regular trash still poses a contamination risk and is not compliant with infection control standards for hazardous materials.

C. Double-bag the dressing in clear bags and label it "biohazard": Although double-bagging and labeling would provide additional precautions, this method is not the standard practice for disposing of contaminated wound dressings. It is more appropriate to use designated biohazard containers for infectious waste rather than using bags.

D. Dispose of the dressing in a biohazardous waste container: This is the correct action. Biohazardous waste containers are specifically designed to safely dispose of materials that may be contaminated with blood, body fluids, or infectious agents. Proper disposal helps to prevent the spread of infection and ensures compliance with safety regulations in healthcare settings.

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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?

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Naxlex Comprehensive Predictor Exams

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

Correct Answer is A

Explanation

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Correct Answer is D

Explanation

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