What stage is a wound if the epidermis is closed and has unblanchable redness?
Stage 1
Stage 2
Stage 3
stage 4
The Correct Answer is A
Choice A rationale
A wound at Stage 1 is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The skin remains unbroken with persistent redness that does not turn white when pressed. This stage indicates that the epidermis is closed.
Choice B rationale
Stage 2 involves partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. This stage is not applicable if the epidermis is closed.
Choice C rationale
Stage 3 is defined by full-thickness skin loss, where fatty tissue is visible in the wound, and granulation tissue and epibole (rolled wound edges) are often present. This stage indicates a more severe wound than what is described in the scenario.
Choice D rationale
Stage 4 represents full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. The condition described does not match the severity of a Stage 4 wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hydrocolloid dressings are used for autolytic debridement, which is a gentle method that allows the body’s enzymes to naturally break down necrotic tissue. This type of dressing maintains a moist wound environment that facilitates the breakdown of dead tissue without damaging healthy tissue.
Choice B rationale
Sharp debridement involves the physical removal of dead tissue using sterile instruments and is not typically performed with a hydrocolloid dressing.
Choice C rationale
Enzymatic debridement uses chemical enzymes to break down necrotic tissue. While enzymatic debridement is a chemical process, it is not synonymous with the use of hydrocolloid dressings.
Choice D rationale
Chemical debridement refers to the use of chemical agents to dissolve necrotic tissue. Hydrocolloid dressings do not contain these agents and are not used for chemical debridement.
Correct Answer is D
Explanation
Choice A rationale
Pointing the device away while opening it is a safe practice to prevent contamination and accidental exposure to bodily fluids.
Choice B rationale
Not touching the drainage spout with the hand is correct as it prevents contamination of the spout, which could lead to infection.
Choice C rationale
Compressing the device before closing it is part of the proper procedure to re-establish the vacuum within the drain, which is necessary for it to function correctly.
Choice D rationale
Using one alcohol wipe to clean both the spout and the plug is incorrect because each should be cleaned with a separate sterile wipe to prevent cross-contamination and maintain sterility.
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