Three days ago, a client was admitted from home with a reported pressure injury. The provider and wound care nurse were at the bedside.
Which statement best describes the most critical aspect of the client's pressure injury and current treatment?
The client was admitted three days ago.
The pressure injury was at stage 4.
The client reported pain as a 2 on a scale from 0 to 10.
The dressing was reapplied and sealed.
The Correct Answer is B
Choice A rationale
The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.
Choice B rationale
The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.
The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative
pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.
Choice C rationale
The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.
Choice D rationale
The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a patient with a living will arrived at the emergency department with difficulty breathing, the healthcare team would provide immediate care to ease the patient’s distress, such as administering oxygen.
Choice B rationale
While a living will outlines a patient’s wishes for end-of-life care, it does not prevent the patient from receiving immediate, necessary care in an emergency situation.
Choice C rationale
Inserting a breathing tube may be necessary in some cases, but it would not be the first step in managing difficulty breathing.
Choice D rationale
While the healthcare team would consult the person appointed by the patient’s healthcare proxy to make decisions, immediate care would not be delayed.
Correct Answer is A
Explanation
Choice A rationale
Auscultating lung sounds is the priority when monitoring for adverse effects of administering IV fluids. Fluid overload can lead to pulmonary edema, which would be detected by abnormal lung sounds such as crackles.
Choice B rationale
While measuring urine output is important to assess kidney function and fluid balance, it is not the priority in this case.
Choice C rationale
Monitoring blood pressure readings is important when administering IV fluids, but it is not the priority in this case.
Choice D rationale
Monitoring electrolyte levels is important when administering IV fluids, but it is not the priority in this case.
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