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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:

The side-lying position allows gravity to assist in wound irrigation and prevent pooling of the solution.

Choice B rationale:

High-Fowler’s position is not ideal for abdominal wound irrigation as it can lead to pooling of the solution.

Choice C rationale:

In the supine position, the solution can pool around the wound and not effectively irrigate it.

Choice D rationale:

The dorsal recumbent position is not ideal as it can also lead to pooling of the solution.

A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle. B. Double bag the dressing, label it "biohazard," and send it for decontamination. C. Place the dressing in a biohazardous waste container. D. Discard the dressing in the bedside trash receptacle.

Correct Answer is C

Explanation

Choice A rationale:

Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

Choice B rationale:

Double bagging the dressing, labeling it “biohazard,” and sending it for decontamination is incorrect because it is not the standard procedure for disposing of soiled dressings.

Choice C rationale:

Placing the dressing in a biohazardous waste container is the correct method for disposing of soiled dressings.

Choice D rationale:

Discarding the dressing in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

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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

After closing the curtain around the client's bed, you lift his gown to expose the horizontal abdominal wound and assist the client into a comfortable position for wound irrigation.Which of the following positions is appropriate for the irrigation of his wound?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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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.