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 A
Explanation
Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
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.
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