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The nurse on the unit is going to perform wound care for her patient.
After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

stage 3.

stage 2.

stage 4.

stage 1.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

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Correct Answer is A

Explanation

Choice A rationale:

Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.

Choice B rationale:

Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

Choice C rationale:

Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.

Choice D rationale:

Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

A. Using a thermometer to check the temperature of the pad. B. Securing the pad to the patient. C. Assisting the patient to lie on top of the pad. D. Instructing the patient not to sleep on the pad. E. Inspecting the plug and cord for cracks or fraying.

Correct Answer is ["A","B","D","E"]

Explanation

E. Using a thermometer to check the temperature of the pad, Securing the pad to the patient, Instructing the patient not to sleep on the pad, Inspecting the plug and cord for cracks or fraying.

Choice A rationale:

It’s important to check the temperature of the pad to prevent burns.

Choice B rationale:

Securing the pad ensures it stays in place and provides consistent heat.

Choice C rationale:

Patients should not lie on top of the pad as it can lead to burns.

Choice D rationale:

Patients should not sleep on the pad to prevent prolonged exposure which can lead to burns.

Choice E rationale:

Inspecting the plug and cord prevents electrical hazards.

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The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

Correct Answer is A

Explanation

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

Moist heat has the physiological effect of:

When applying an ice pack, it is necessary to:

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Superficial wounds heal faster when kept:

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

The nurse on the unit is going to perform wound care for her patient.
After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.