The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Debride the wound.

Manage drainage from the wound.

Document the wound.

Monitor the wound.

Answer and Explanation

The Correct Answer is A

A: Debriding the wound is the next step for a black (necrotic) pressure ulcer. Removing the dead tissue is essential to promote healing and prevent infection.

B: Managing drainage is important for wound care but is not the immediate next step for a necrotic ulcer.

C: Documenting the wound is necessary but does not address the need for debridement.

D: Monitoring the wound is important, but active intervention (debridement) is required for a necrotic ulcer to promote healing.

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Correct Answer is B

Explanation

A: Auscultation, or listening for air injected into the tube, is not a reliable method for verifying feeding tube placement. It can lead to false positives and does not confirm the tube’s location accurately.

B: X-ray is the gold standard for verifying feeding tube placement. It provides a clear image of the tube’s position, ensuring it is correctly placed in the stomach or small intestine, reducing the risk of complications.

C: Aspiration of contents can help verify placement by checking the appearance and pH of the aspirate. However, it is not as definitive as an X-ray and can sometimes be inconclusive.

D: pH testing of aspirate can indicate whether the tube is in the stomach (acidic pH) or intestines (less acidic). While useful, it is not as reliable as an X-ray for confirming placement.

A. Intact skin with localized erythema. B. Full-thickness skin loss with visible adipose tissue. C. Partial-thickness skin loss with red tissue in wound bed. D. Full-thickness skin loss with visible bone.

Correct Answer is C

Explanation

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

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The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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