A nurse begins her shift and is completing her first turn of the night. While turning, she also assesses her patient's skin. When she turns her patient she finds the following wound on her coccyx. How should she document the following wound? (The base of the wound is muscle, with some subcutaneous tissue)

Stage III Pressure Ulcer

Stage IV Pressure Ulcer

Stage II Pressure Ulcer

Unstageable Ulcer

Answer and Explanation

The Correct Answer is B

Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale: Carrying an air-filled ball while wading through the water across the width of a pool is an isotonic exercise.
Choice B rationale: Contracting the gluteal muscles while holding a simple yoga pose is an isometric exercise.
Choice C rationale: Walking at a rate of 3 miles (5 km)/hour around a racetrack is an isotonic exercise.
Choice D rationale: Sitting in a chair with a low weight on the side and lifting the knee to the seat level of the chair is an isotonic exercise.

A. Removing excess drainage and wet tissue to prevent maceration of surrounding skin B. Stimulating the wound bed to promote the growth of granulation tissue C. Removing purulent drainage from the wound bed in order to accurately assess it D. Removing dead or infected tissue to promote wound healing

Correct Answer is D

Explanation

Choice A rationale: Removing excess drainage and wet tissue to prevent maceration is more related to wound care than debridement.
Choice B rationale: Stimulating the wound bed to promote the growth of granulation tissue is a goal of debridement.
Choice C rationale: Removing purulent drainage from the wound bed is more related to wound care than debridement.
Choice D rationale: The primary goal of debridement is to remove dead or infected tissue to promote wound healing and create an environment conducive to tissue regeneration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic. Isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

Correct Answer is B

Explanation

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

Correct Answer is D

Explanation

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

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

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?