A patient presents with a pressure injury on their sacral region, The wound bed is moist, pinkish-red, and shallow, with no slough or eschar visible. What is the most appropriate classification for this injury?
Unstageable Pressure Injury
Stage 2 Pressure Injury
Stage 1 Pressure Injury
Stage 3 Pressure Injury
The Correct Answer is B
A. Unstageable Pressure Injury: Unstageable injuries involve full-thickness tissue loss in which the wound bed is covered by slough or eschar, making the depth indeterminable. This does not describe the patient’s shallow, pink-red wound.
B. Stage 2 Pressure Injury: Stage 2 injuries are characterized by partial-thickness loss of dermis presenting as a shallow, open ulcer with a pink or red wound bed, without slough or eschar. The patient’s moist, shallow, pink-red sacral wound fits this classification.
C. Stage 1 Pressure Injury: Stage 1 injuries present as non-blanchable erythema of intact skin. Since the patient has a shallow open wound with partial-thickness loss, this stage is not appropriate.
D. Stage 3 Pressure Injury: Stage 3 injuries involve full-thickness tissue loss with visible subcutaneous fat, which may extend to but not through underlying fascia. The patient’s wound is shallow with partial-thickness loss, so stage 3 does not apply.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wipe from front to back after using the restroom: This intervention reduces the transfer of fecal bacteria (commonly E. coli) from the perineal area to the urethra, directly targeting the mode of transmission in the chain of infection. Proper hygiene interrupts the pathway for bacterial entry into the urinary tract.
B. Increase fluid intake to flush out bacteria: Drinking adequate fluids helps dilute urine and promote urinary flow, which aids in clearing bacteria. While preventive, this action affects the host defense rather than the mode of transmission.
C. Take prescribed antibiotics as directed: Completing antibiotics prevents persistence or recurrence of infection by eliminating existing bacteria. This addresses the infectious agent rather than the transmission pathway.
D. Avoid using scented hygiene products: Scented soaps or feminine hygiene sprays can irritate the urethra and alter normal flora, but this primarily affects host susceptibility rather than the mode of transmission.
Correct Answer is B
Explanation
A. Introduce a blanket and stuffed animal to comfort the baby: Loose bedding and soft toys in the crib increase the risk of sudden infant death syndrome (SIDS) in newborns. This action is unsafe and not recommended for infants under 12 months.
B. Check for hunger, wet diaper, or cold and fix the issue quietly using minimal light and noise: Newborns wake frequently for basic needs. Addressing hunger, diaper changes, or temperature issues in a calm, quiet manner promotes restorative sleep and supports safety. Minimizing stimulation helps the baby return to sleep more easily.
C. Allow the baby to cry until they fall back asleep naturally: Letting a newborn “cry it out” is not appropriate at this age. Infants rely on caregivers for feeding, warmth, and comfort. Ignoring these needs can cause distress and disrupt healthy attachment.
D. Keep the baby awake during the day to reduce nighttime waking: Newborns have irregular sleep-wake cycles, and forcing wakefulness can lead to overtiredness, irritability, and difficulty feeding. Daytime sleep is essential for growth and development at this age.
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