The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
You would document this wound as:
stage 1.
unstageable.
deep tissue injury.
stage 2.
The Correct Answer is B
Choice A rationale:
A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.
Choice B rationale:
Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Choice C rationale:
Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Choice D rationale:
A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice B rationale:
Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.
Choice C rationale:
Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice D rationale:
Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
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.
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