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 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.
Correct Answer is B
Explanation
Choice A rationale:
Third intention healing, also known as delayed primary closure, is used when wound closure is delayed due to infection risk.
Choice B rationale:
First intention healing occurs when the wound edges are approximated, such as with sutures.
Choice C rationale:
Second intention healing occurs when the wound edges cannot be approximated and the wound heals from the bottom up.
Choice D rationale:
Fourth intention healing is not a recognized term in wound healing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.