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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.)

Increased immunity.

Atherosclerosis.

Slow metabolism.

Excessive production of blood factors.

Diminished lung function.

Answer and Explanation

Correct Answer : A,B,C,E

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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Correct Answer is C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A. Purulent. B. Serous. C. Sanguinous. D. Serosanguineous.

Correct Answer is D

Explanation

Choice A rationale:

Purulent drainage is thick and often has a foul odor. It is often a sign of infection and can have a variety of colors, including yellow, green, or brown. This is not the correct choice because the description does not match the question.

Choice B rationale:

Serous drainage is clear and watery, often seen in normal healing processes. This is not the correct choice because the description does not match the question.

Choice C rationale:

Sanguinous drainage is fresh blood, often seen in deep wounds or when a wound is disturbed. This is not the correct choice because the description does not match the question.

Choice D rationale:

Serosanguineous drainage is a mixture of blood and serous fluid, often seen in new wounds. This matches the description given in the question.

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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.)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

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.

Correct Answer is D

Explanation

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:

A nurse is caring for a client who is at risk for a pressure injury.Which of the following actions should the nurse take?

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?

The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

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:

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?