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. .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Massaging bony prominences can lead to tissue ischemia and damage, increasing the risk of pressure injuries.
Choice B rationale:
Repositioning should be done every 2 hours or less for at-risk patients.
Choice C rationale:
Elevating the head of the bed more than 30° can increase shear and friction, leading to pressure injuries.
Choice D rationale:
A high-calorie diet can promote skin integrity and wound healing.
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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