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:

pressure injury.

stage 2.

stage 1.

stage 3.

stage 4. .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

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

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

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

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

A. Side-lying. B. High-Fowler's. C. Supine. D. Dorsal Recumbent.

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.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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

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Enter instructional text.The nurse clarifies that the second stage of wound healing is:

What type of wound heals by delaying the suturing until the infection is resolved?

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

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: