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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 D

Explanation

Choice A rationale:

Purulent indicates pus, which is not described here.

Choice B rationale:

Infection usually presents with redness, swelling, and possibly pus, which is not described here.

Choice C rationale:

Debridement is the removal of dead tissue, not indicated by a pinkish-red bumpy area.

Choice D rationale:

A pinkish-red center area that looks bumpy indicates granulation tissue, which is a sign of healing.

A. Increased immunity. B. Atherosclerosis. C. Slow metabolism. D. Excessive production of blood factors. E. Diminished lung function.

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

Explanation

Choice A rationale:

Increased immunity is not a characteristic of aging. In fact, immunity decreases with age, which can slow healing.

Choice B rationale:

Atherosclerosis, or hardening of the arteries, can reduce blood flow to tissues and slow healing.

Choice C rationale:

Metabolism slows with age, which can delay the body’s ability to repair and regenerate tissues.

Choice D rationale:

Excessive production of blood factors is not a characteristic of aging. Blood factors are typically produced in response to injury or illness.

Choice E rationale:

Diminished lung function can reduce oxygen supply to tissues, slowing healing.

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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.

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Naxlex Comprehensive Predictor Exams

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:

Correct Answer is D

Explanation

The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

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

Explanation

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

Which type of debridement is a hydrocolloid dressing used for?

When giving a hot soak treatment, it is most important to:

When preparing to change a sterile dressing over an incision, it is most important to remember to:

A nurse is removing a wound dressing that is saturated with blood and purulent drainage.Which of the following methods should the nurse use when disposing of the soiled dressing?

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

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.