A patient has a pooling of blood under unbroken skin of the hip after a fall.
The nurse should document that this patient has a(n):

abrasion.

avulsion.

hematoma.

laceration.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

An abrasion is a superficial injury to the skin caused by scraping or rubbing, which does not match the description of a pooling of blood under unbroken skin.

Choice B rationale:

An avulsion is a wound where a chunk of tissue is torn away, which does not match the description of a pooling of blood under unbroken skin.

Choice C rationale:

A hematoma is a pooling of blood outside of blood vessels, typically caused by trauma. It matches the description of a pooling of blood under unbroken skin.

Choice D rationale:

A laceration is a deep cut or tear in the skin, which does not match the description of a pooling of blood under unbroken skin.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.

A. Keep the wound dry. B. Help destroy microorganisms in an infected wound. C. Leave the dressing in place for 10 days. D. Occlude air and promote breakdown of necrotic tissue.

Correct Answer is D

Explanation

Choice A rationale:

Hydrocolloid dressings do not keep the wound dry; they maintain a moist environment.

Choice B rationale:

These dressings do not have antimicrobial properties.

Choice C rationale:

While these dressings can be left in place for several days, it is not their major purpose.

Choice D rationale:

Hydrocolloid dressings occlude air and promote autolytic debridement of necrotic tissue.

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A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D","E"]

Explanation

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

Correct Answer is D

Explanation

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A patient has a pooling of blood under unbroken skin of the hip after a fall.
The nurse should document that this patient has a(n):