When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Perform hand hygiene.

Assess the condition of the visible wound bed.

Measure the width of the wound with a disposable ruler.

Insert a swab into the wound at 90 degrees.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

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Correct Answer is A

Explanation

Choice A rationale: The statement "I need to void after sexual intercourse to flush microorganisms away from my urethra" is correct. Voiding after sexual intercourse can help prevent the ascent of microorganisms into the urethra and reduce the risk of urinary tract infections.
Choice B rationale: Wearing snug-fitting pants can contribute to a warm and moist environment, potentially increasing the risk of urinary tract infections rather than preventing them.
Choice C rationale: Wiping from the anus to the vagina after going to the bathroom can introduce microorganisms into the urethral area, increasing the risk of urinary tract infections.
Choice D rationale: Frequent bubble baths can disrupt the natural balance of microorganisms in the genital area and increase the risk of urinary tract infections.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Ulcer D. Stage IV Pressure Ulcer

Correct Answer is A

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

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When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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