The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?

Stage I Pressure Ulcer

Stage III Pressure Ulcer

Healing Stage III Pressure Ulcer

Healing Stage II Pressure Ulcer

Answer and Explanation

The Correct Answer is C

A. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification.

B. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition.

C. Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes "healing" to show improvement.

D. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.

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Correct Answer is D

Explanation

A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.

B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.

C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.

D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.

A. Remove all metal necklaces. B. Take several shallow breaths during the procedure. C. Do not eat or drink anything the morning of the test D. Expect minor discomfort after the procedure

Correct Answer is A

Explanation

A. Remove all metal necklaces. Metal can obscure the x-ray image, so all metal jewelry, piercings, and clothing with metal components should be removed.

B. Take several shallow breaths during the procedure. Patients should take a deep breath and hold it during the x-ray to expand the lungs fully for clearer imaging.

C. Do not eat or drink anything the morning of the test. Fasting is not needed for a chest x-ray; it is typically required for procedures like CT scans with contrast or abdominal ultrasounds.

D. Expect minor discomfort after the procedure. A chest x-ray is non-invasive and painless. There is no expected discomfort afterward.

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The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?

Nursing Test Bank

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