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 A
Explanation
Choice A rationale:
Dakin’s solution is used for chemical debridement, which involves the use of a chemical, such as Dakin’s solution, to break down and remove dead tissue.
Choice B rationale:
Primary intention is a term used to describe the healing of a clean wound without tissue loss. Dakin’s solution does not directly contribute to this process.
Choice C rationale:
While Dakin’s solution can aid in the healing process by preventing and treating infections, it does not directly cause healing.
Choice D rationale:
Phagocytosis is a process carried out by certain cells in the body to engulf and destroy pathogens or debris. Dakin’s solution does not perform this function.
Correct Answer is A
Explanation
Choice A rationale:
Dakin solution is used for chemical debridement of a wound.
Choice B rationale:
Primary intention is a method of wound healing, not a result of Dakin solution.
Choice C rationale:
While Dakin solution can aid in wound healing, it does not directly cause healing.
Choice D rationale:
Phagocytosis is a process carried out by certain cells in the body, not a result of Dakin solution.
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