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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.

A. Encourage fluid intake B. Reduce fluid intake C. Alert the healthcare provider of possible infection D. No action is required

Correct Answer is A

Explanation

Choice A rationale: Dark yellow urine may indicate concentrated urine, and encouraging fluid intake helps dilute the urine, promoting kidney function and preventing dehydration.
Choice B rationale: Reducing fluid intake is not appropriate based solely on the color of the urine. It is essential to assess overall hydration status.
Choice C rationale: Dark yellow urine alone does not necessarily indicate infection. Other symptoms and laboratory tests would be needed for a diagnosis.
Choice D rationale: Taking no action is not appropriate when the color of urine suggests dehydration. Assessing and addressing hydration status are important.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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