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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.
Choice B rationale:
The irrigant should be at room temperature, not chilled.
Choice C rationale:
The syringe should be held 1 inch (not 0.5 inch) from the wound.
Choice D rationale:
The wound should be flushed from the cleanest area to the most contaminated, not the other way around.
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.
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