The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?
Stage 1
Stage 2
Stage 3
Stage 4
The Correct Answer is B
Choice A rationale
Stage 1 wounds are characterized by non-blanchable redness of intact skin. The presence of partial-thickness skin loss indicates that the wound has progressed beyond stage 1, making this choice incorrect.
Choice B rationale
Stage 2 wounds involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This description matches the nurse’s assessment of the patient’s wound, confirming that it is indeed a stage 2 wound.
Choice C rationale
Stage 3 wounds exhibit full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s wound, with partial-thickness skin loss and no mention of exposed subcutaneous structures, does not fit the criteria for stage 3.
Choice D rationale
Stage 4 wounds involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The patient’s wound does not have these characteristics, ruling out stage 4.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse’s first priority should always be to assess the patient’s condition. In the context of NPWT, this means checking for any complaints or problems in the wound area. This assessment helps to ensure that the NPWT is not causing additional issues and that the wound is healing as expected.
Choice B rationale
While it is important to check the settings on the NPWT unit to ensure it is functioning correctly, this is not the first priority. The patient’s well-being and response to treatment take precedence over equipment checks.
Choice C rationale
Documentation is a critical part of patient care, but it comes after patient assessment and any necessary interventions. It serves to record the patient’s status and the care provided but is not the immediate priority.
Choice D rationale
Observing the dressing area is part of the overall assessment of the patient and the effectiveness of the NPWT. However, it is not the first action to take. The nurse must first assess the patient for any discomfort or complications before focusing on the dressing itself.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale
Keeping the skin and surrounding tissue clean and dry helps prevent infection, which is crucial for proper wound healing. A clean environment is less likely to harbor bacteria that can cause complications.
Choice B rationale
Proper nutrition, particularly adequate protein and vitamins, provides the necessary building blocks for tissue repair and supports the immune system, which is essential for healing.
Choice C rationale
Resting and minimizing movement of the incisional area help prevent further injury and allow the body’s resources to focus on the healing process.
Choice D rationale
While fluid intake is important, 4000 mL per day may be excessive unless specifically recommended for the patient’s condition. Overhydration can be harmful.
Choice E rationale
Exercise and deep breathing increase blood flow and oxygenation to tissues, which are vital for healing. Oxygen is needed for cellular functions that repair tissue.
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