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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["890"]
Explanation
Answer= 890 ml
To calculate the total intake, we need to convert all the volumes to a common unit, such as milliliters (mL).
- Clear soda: 4 oz = 120 mL (1 oz = 30 mL)
- Toast: Assuming 1 slice of toast is approximately 50 mL.
- Water: 12 oz = 360 mL (1 oz = 30 mL)
- Fruit-flavored gelatin: 1 cup = 240 mL
- Chicken broth: 1/2 cup = 120 mL
Now, add up all the intakes:
- 120 mL + 50 mL + 360 mL + 240 mL + 120 mL = 890 mL
Correct Answer is B
Explanation
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.