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 ["B","C","D"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

A. there is probably a deeper injury than what appears on the surface. B. he has lain in one position for such a long time that swelling has occurred. C. vessels have dilated and allowed plasma to leak into the wound site. D. an infection is in progress at the wound site.

Correct Answer is C

Explanation

Choice A rationale:

There is probably a deeper injury than what appears on the surface is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice B rationale:

He has lain in one position for such a long time that swelling has occurred is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice C rationale:

Vessels have dilated and allowed plasma to leak into the wound site is the correct answer because this is a normal part of the inflammatory stage of wound healing.

Choice D rationale:

An infection is in progress at the wound site is incorrect because while swelling can be a sign of infection, it is also a normal part of the inflammatory stage of wound healing.

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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 collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D"]

Explanation

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:

Correct Answer is C

Explanation

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

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.

The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

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

A nurse is removing a wound dressing that is saturated with blood and purulent drainage.Which of the following methods should the nurse use when disposing of the soiled dressing?

The nurse places Dakin solution in a wound to accomplish chemical:

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

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.