The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?
Stage IV
Stage II
Stage III
Unstageable
The Correct Answer is D
D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable
A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.
B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.
C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This is the best response. It demonstrates empathy, active listening, and a willingness to understand the client's emotions. By inviting the client to express their feelings further, the nurse creates an opportunity for therapeutic communication and can better assess how to support the client emotionally.
A. This response dismisses the client's feelings of anger and sadness and may come across as minimizing their emotions. It does not acknowledge the client's current state of distress or provide validation for their feelings.
C. This response expresses empathy and acknowledges the client's feelings, which is important. However, it may seem somewhat passive and could benefit from further exploration or invitation for the client to elaborate on their feelings.
D. This response is dismissive and judgmental. It may make the client feel invalidated or criticized for expressing their emotions, which can further escalate feelings of anger or distress.
Correct Answer is ["B","E"]
Explanation
B Droplet precautions are used for pathogens that can be transmitted through respiratory droplets produced when an infected person coughs, sneezes, talks, or during procedures such as suctioning.
E. Healthcare workers should wear a surgical mask when within close proximity (within 3 feet) of a patient on droplet precautions. The mask helps prevent the inhalation of droplets that may contain infectious pathogens.
A. Negative pressure rooms are used for airborne precautions, not droplet precautions. Droplet precautions typically do not require negative pressure rooms.
C. Infections transmitted on air currents are managed with airborne precautions, not droplet precautions. Droplet transmission occurs over shorter distances (generally within 3 feet) due to larger respiratory droplets.
D. An N-95 mask is used for airborne precautions to filter smaller particles. For droplet precautions, healthcare workers typically wear a surgical mask to protect against larger respiratory droplets.
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