When caring for clients with pressure injuries, it is important to know what stage the wound is before wound care can begin. What two things prevent a pressure injury from being stageable and healing?
Odor & Discharge
Depth & Redness
Size & Shape
Eschar or Slough
The Correct Answer is D
A. Odor & Discharge: Odor and drainage (exudate) can signal infection or heavy exudation and affect wound care decisions, but they do not by themselves make a wound unstageable -they do not obscure the wound base.
B. Depth & Redness: Depth is a key element used to stage a pressure injury (superficial vs full-thickness), and redness describes superficial inflammation; neither of these alone prevents staging when the wound bed is visible.
C. Size & Shape: Size and shape are important for documentation and tracking healing but do not prevent staging if the wound bed can be inspected.
D. Eschar or Slough: Eschar (black, necrotic tissue) or slough (yellow/gray nonviable tissue) can cover the wound base and obscure depth, preventing accurate staging and often delaying healing until the nonviable tissue is managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sit beside the client and ask how his care team can best support his spiritual needs: Sitting with the client, showing presence, and asking an open question honors the client's expressed spirituality and allows the nurse to assess and facilitate appropriate support (e.g., chaplain, family involvement, reading scripture).
B. Avoid eye contact and call a chaplain for the client to talk to about spiritual matters: Calling a chaplain can be appropriate, but avoiding eye contact and withdrawing from the moment neglects immediate emotional support the nurse can provide.
C. Place a sign on the door to allow the client some quiet time in the mornings: Providing privacy may be useful, but it does not respond to the client’s expressed emotion or request in the moment.
D. Tell the client that his spirituality is impressive: Praising or judging the client’s spirituality shifts focus to the nurse’s view rather than supporting the client’s needs; a reflective, empathetic response is more therapeutic.
Correct Answer is A
Explanation
A. The client remains free of contractures: Maintaining joint range of motion with passive ROM and appropriate splinting prevents shortening of muscles and connective tissue, preserving functional positioning and preventing contractures.
B. The client continues to have diarrhea: Diarrhea is unrelated to passive ROM and splinting goals; its persistence would not indicate that mobility-preserving goals were met.
C. Renal calculi are present in the client's kidneys: Immobility increases the risk of calcium mobilization and stone formation, so presence of renal calculi indicates a complication rather than an achieved goal.
D. Atelectasis is present on auscultation: Atelectasis is a pulmonary complication associated with immobility and shallow breathing; its presence suggests a goal related to preventing respiratory complications was not achieved.
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