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 D
Explanation
Choice A rationale
An abrasion occurs when the skin is scraped off, usually due to a surface rubbing or scraping against the skin. It does not involve pooling of blood under the skin but rather an injury to the top layer of the skin.
Choice B rationale
An avulsion is a severe type of wound that occurs when a portion of the skin and sometimes the tissue beneath is partially or completely torn away. It is not characterized by pooling of blood under unbroken skin.
Choice C rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because lacerations imply that the skin is broken and torn, it does not describe the condition where blood pools under unbroken skin.
Choice D rationale
A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This is the correct term for a pooling of blood under unbroken skin, as described in the scenario following the patient’s fall. Hematomas can be caused by injury, such as a fall, that causes blood vessels to break and bleed into the surrounding tissues.
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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