A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?
Deep Tissue Injury
Stage III Pressure Ulcer
Unstageable Ulcer
Stage IV Pressure Ulcer
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Using enemas should not be the first response to constipation. There are various types of laxatives with different mechanisms of action that can be tried before resorting to enemas.
Choice B rationale: Habitual laxative use can contribute to chronic constipation, but it is not the most common cause. It is essential to identify and address the underlying cause of constipation.
Choice C rationale: If laxatives are not effective, trying a laxative with a different mechanism of action may be more successful in relieving constipation.
Choice D rationale: Chronic constipation should be assessed and addressed, as it can lead to complications and should not be dismissed as insignificant.
Correct Answer is A
Explanation
Choice A rationale: Stool expelled into an ileostomy bag is often of liquid consistency. An ileostomy involves the diversion of the small intestine, where the stool is more liquid compared to a colostomy, which involves the large intestine and typically produces more formed stool.
Choice B rationale: Bloody stool is not a typical characteristic of stool from an ileostomy.
Choice C rationale: Mucus-filled stool is not the primary characteristic of stool from an ileostomy.
Choice D rationale: Soft semi-formed stool is not typical of an ileostomy; the stool is more liquid in consistency.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.