The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.
Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Stage 1.

Stage 3.

Stage 2.

Stage 4.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

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Correct Answer is A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

A. Alginate. B. Dry gauze. C. Hydrogel. D. Transparent.

Correct Answer is A

Explanation

Choice A rationale:

Alginate dressings are highly absorbent and suitable for wounds with heavy drainage. They also promote hemostasis by activating the intrinsic pathway of the clotting cascade.

Choice B rationale:

Dry gauze is not the best choice for a bleeding wound as it does not have hemostatic properties.

Choice C rationale:

Hydrogel dressings are primarily for wounds with little to no exudate and not suitable for a bleeding wound.

Choice D rationale:

Transparent dressings are thin, waterproof dressings used for superficial wounds and not suitable for a bleeding wound.

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The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

Correct Answer is A

Explanation

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.The nurse's most beneficial intervention would be to:

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.
Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.