The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?
Surgical debridement of the wound
Increased drainage from the wound
Documenting the wound status daily
Increased monitoring of the wound condition
The Correct Answer is A
Choice A rationale
A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement.
Choice B rationale
Increased drainage from the wound is not typically associated with a black pressure ulcer.
Choice C rationale
While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
Choice D rationale
Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
Correct Answer is C
Explanation
Choice A rationale
Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.
Choice B rationale
Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.
Choice C rationale
In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
Choice D rationale
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.
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