A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

Deep Tissue Injury

Stage III Pressure Ulcer

Unstageable Pressure Ulcer

Stage II Pressure Ulcer

Answer and Explanation

The Correct Answer is C

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

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Correct Answer is D

Explanation

A. Medicate the client for pain: Pain management is essential after surgery; however, it is not the most critical action. Unrelieved pain could indicate a complication, such as compartment syndrome, which requires further assessment.

B. Direct the client to perform exercises of the ankle and toes: Performing ankle and toe exercises helps prevent complications such as venous thromboembolism (VTE) and promotes circulation, but it is not the priority over assessing for complications.

C. Instruct the client on the use of crutches: Teaching the client how to use crutches is important for mobility, but this is not the most immediate postoperative concern.

D. Perform neurovascular checks of the extremities: This is the most important intervention because neurovascular compromise (e.g., compartment syndrome) can occur after orthopedic surgery. Checking circulation, movement, and sensation (CMS) is critical for early detection of complications.

A. “I will keep my cast dry and avoid inserting objects inside to scratch my skin." B. "If I notice increased swelling, numbness, or severe pain, I will elevate my leg and notify my provider immediately." C. "It's okay to use a blow dryer on a cool setting to help dry my cast if it gets wet." D. “I should expect to feel extreme pain under the cast that doesn't improve with pain medication."

Correct Answer is D

Explanation

A. “I will keep my cast dry and avoid inserting objects inside to scratch my skin.” Keeping the cast dry prevents it from softening or breaking down, which could lead to improper healing. Avoiding objects inside the cast prevents skin injuries and infections.

B. "If I notice increased swelling, numbness, or severe pain, I will elevate my leg and notify my provider immediately." Increased swelling, numbness, and severe pain can indicate compartment syndrome or impaired circulation. Elevating the leg and seeking medical attention is appropriate.

C. "It's okay to use a blow dryer on a cool setting to help dry my cast if it gets wet." A blow dryer on a cool setting can be used to help dry moisture inside the cast without causing burns or affecting the cast material.

D. “I should expect to feel extreme pain under the cast that doesn't improve with pain medication.” Extreme pain that is unrelieved by medication is abnormal and may indicate complications like compartment syndrome, infection, or pressure ulcers under the cast. The patient needs further education that severe pain should be reported immediately.

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A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

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