The nurse is assessing a client for a Stage III (Stage 3) Pressure injury. The nurse knows that which of the following are characteristics of a Stage 3 pressure injury? SELECT ALL THAT APPLY
Full thickness skin loss of the subcutaneous tissue.
A deep purplish area is noted.
A shallow wound bed is present.
No visible bone, tendon and ligaments are noted.
Visible bone, tendon and ligaments are noted.
Correct Answer : A,D
A. Full thickness skin loss of the subcutaneous tissue: Stage 3 pressure injuries involve full-thickness loss of the skin extending through the dermis into the subcutaneous tissue. The subcutaneous fat may be visible, and the depth of the wound varies by anatomical location, making this a defining characteristic of Stage 3 injuries.
B. A deep purplish area is noted: A deep purplish or maroon area is more characteristic of a suspected deep tissue injury rather than a Stage 3 pressure injury. These injuries involve underlying tissue damage beneath intact or minimally broken skin and may not involve full-thickness loss of subcutaneous tissue at this stage.
C. A shallow wound bed is present: Shallow wounds are typical of Stage 2 pressure injuries, which involve partial-thickness loss of dermis and present as open, superficial ulcers. Stage 3 wounds are deeper and extend through the full thickness of the skin into subcutaneous tissue.
D. No visible bone, tendon, and ligaments are noted: In Stage 3 pressure injuries, the bone, tendon, or muscle is not exposed. The injury extends into subcutaneous tissue but stops short of deeper structures, distinguishing it from Stage 4 pressure injuries.
E. Visible bone, tendon, and ligaments are noted: Exposure of bone, tendon, or ligaments indicates a Stage 4 pressure injury, which involves full-thickness tissue loss with damage extending into underlying structures. This finding exceeds the depth seen in Stage 3 injuries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Annual pap smear: Routine Pap smears are generally not recommended for women older than 65 who have had adequate prior screening and are not at high risk for cervical cancer. Continuing Pap smears in this age group offers minimal benefit for disease prevention, making it a lower priority compared with vaccinations that prevent life-threatening infections.
B. Pneumococcal immunization: Pneumococcal vaccination is highly recommended for adults aged 65 and older because aging increases susceptibility to pneumococcal infections, including pneumonia, bacteremia, and meningitis. Immunization significantly reduces morbidity and mortality in this population, making it the highest priority in older adults.
C. Annual mammogram: While mammography is important for early detection of breast cancer, current guidelines typically recommend individualized decision-making for women aged 70 and older, especially if life expectancy is limited or comorbidities exist. Vaccinations provide broader population-level protection against serious infections and thus take precedence.
D. Human papilloma virus (HPV) immunization: HPV vaccination is primarily targeted toward adolescents and young adults up to age 26, with some recommendations extending to 45. For adults over 70, HPV immunization does not provide meaningful protection, as exposure risk is low and immune response may be diminished, making it irrelevant for this age group.
Correct Answer is C
Explanation
A. Notify the physician immediately of this unexpected finding: While loss of suction should be reported if it cannot be corrected, immediate notification is not the first action. The nurse should first attempt standard troubleshooting to re-establish suction, as this is often a correctable issue without needing urgent physician intervention.
B. Allow gravity to assist with draining by repositioning the drain to a position lower than the client: Positioning the drain lower may facilitate passive drainage, but it does not restore the negative pressure needed for the Jackson-Pratt drain to function effectively. Relying solely on gravity can lead to fluid accumulation and increase the risk of infection.
C. Re-establish the negative pressure by opening the valve and decompressing the bulb: The Jackson-Pratt drain relies on negative suction to remove fluid from the wound site. If suction is lost, the nurse should compress the bulb after emptying it and closing the valve to restore negative pressure, ensuring continued drainage and reducing the risk of hematoma, or infection.
D. Switch the client's drain to a Hemovac drain to improve suction: Replacing the drain is not the first-line action. Hemovac drains are a different device, and switching requires a physician’s order. The priority is to troubleshoot and restore the function of the existing Jackson-Pratt drain before considering device replacement.
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