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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: A purplish-colored stoma may indicate compromised blood supply and should be reported to the provider.
Choice B rationale: A shiny, moist stoma is a healthy characteristic of a colostomy. Choice C rationale: Stoma oozing red drainage is a normal finding after colostomy surgery.
Choice D rationale: "Budded" stoma is not a recognized term related to colostomy assessment.
Correct Answer is D
Explanation
Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.
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