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 C
Explanation
Choice A rationale
When administering a hot soak treatment, it is crucial to soak only the affected area to provide targeted heat therapy. This localized approach helps to increase blood flow, reduce pain, and promote healing in the specific area that requires treatment. Soaking only the affected area also minimizes the risk of overheating and potential burns to other parts of the body.
Choice B rationale
While positioning the patient comfortably is important for any treatment, it is not the most critical aspect of a hot soak treatment. Comfort should always be considered, but the primary goal of the hot soak is to apply heat to the affected area to aid in healing. Therefore, ensuring that only the affected area is soaked takes precedence over general patient comfort in this context.
Choice C rationale
Monitoring the temperature of the water is the most important aspect of a hot soak treatment. The water must be warm enough to be therapeutic but not so hot as to cause burns or discomfort. This ensures the treatment is both safe and effective1.
Choice D rationale
Checking the patient’s skin integrity is important, especially if the patient has a condition that affects skin sensitivity, such as diabetes. However, the immediate concern during a hot soak treatment is to monitor the temperature to prevent injury.
Correct Answer is D
Explanation
Choice A rationale
While an abdominal binder may be helpful postoperatively, it is not the immediate intervention for a patient who feels that ‘something just let go’ after surgery.
Choice B rationale
Seating the patient in a nearby chair is not the best initial action as it may increase abdominal pressure and potentially worsen any underlying issue.
Choice C rationale
Instructing the patient to pant is not an appropriate response to a potential complication from surgery, such as dehiscence or evisceration.
Choice D rationale
The best initial action is to assist the patient into a supine position to minimize tension on the abdominal incision, reduce the risk of further injury, and assess the situation.
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