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 D

Explanation

Choice A rationale:

Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.

Choice B rationale:

Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.

Choice C rationale:

Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.

Choice D rationale:

Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.

A. A client who is alert and responsive and eats 25% of each meal. B. A client who is unresponsive to verbal commands and changes position occasionally. C. A client who makes frequent slight changes in position and walks occasionally. D. A client who is receiving enteral feeding and can change position independently.

Correct Answer is B

Explanation

Choice A rationale:

An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.

Choice B rationale:

A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.

Choice D rationale:

A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.

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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.

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Naxlex Comprehensive Predictor Exams

When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

Correct Answer is D

Explanation

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is B

Explanation

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.You would document this wound as:

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

Which type of debridement is a hydrocolloid dressing used for?

When applying an ice pack, it is necessary to:

A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

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.