The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Stage 1 pressure ulcer

Stage 4 pressure ulcer

Stage 2 pressure ulcer

Stage 3 pressure ulcer

Answer and Explanation

The Correct Answer is D

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

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Correct Answer is A

Explanation

A. Using a moisturizer after cleaning helps keep the skin hydrated, preventing dryness and cracking, which can increase the risk of infection.

B. Allowing the skin to air dry can lead to excessive dryness, especially in vulnerable areas, potentially compromising the skin’s integrity.

C. Rubbing the skin firmly can cause irritation, damage, and increased risk of skin breakdown, particularly in individuals with fragile skin.

D. Washing the skin daily with hot water can strip the skin of natural oils, leading to dryness and irritation, which increases the risk of infection. Warm water should be used instead.

A. A postoperative client whose blood pressure at 0800 was 138/86 mm Hg and now at 1000 is 90/60 mm Hg B. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 100 mg/dL C. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous D. A client who reports pain as 1 on a scale of 1 to 10 at 0800 now reports pain as 3

Correct Answer is A

Explanation

A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.

B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.

C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.

D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.

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The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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