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?
Unstageable Ulcer
Stage II Pressure Ulcer
Stage IV Pressure Ulcer
Stage III Pressure Ulcer
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Stool expelled into an ileostomy bag is often of liquid consistency. An ileostomy involves the diversion of the small intestine, where the stool is more liquid compared to a colostomy, which involves the large intestine and typically produces more formed stool.
Choice B rationale: Bloody stool is not a typical characteristic of stool from an ileostomy.
Choice C rationale: Mucus-filled stool is not the primary characteristic of stool from an ileostomy.
Choice D rationale: Soft semi-formed stool is not typical of an ileostomy; the stool is more liquid in consistency.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale: A physician's order is typically required for a digital removal of a fecal impaction.
Choice B rationale: Using a lubricated index finger to break up some of the mass and remove it is a correct step in the procedure.
Choice C rationale: Sterile gloves are not required for a digital removal of a fecal impaction. Clean gloves are generally sufficient.
Choice D rationale: The mass may need to be broken up into smaller pieces for removal, rather than being removed as a whole.
Choice E rationale: The patient is usually positioned in a side-lying position for comfort and accessibility during the procedure.
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