A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

Unstageable Ulcer

Stage II Pressure Ulcer

Stage IV Pressure Ulcer

Stage III Pressure Ulcer

Answer and Explanation

The Correct Answer is A

Choice A rationale: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.

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Correct Answer is A

Explanation

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

A. percussion. B. deep palpation. C. auscultation. D. light palpation.

Correct Answer is C

Explanation

Choice A rationale: Percussion is typically performed after auscultation in the abdominal assessment sequence.
Choice B rationale: Deep palpation is usually performed after light palpation in the abdominal assessment sequence.
Choice C rationale: Auscultation is the next step in the abdominal assessment sequence after inspection. Assessing bowel sounds is crucial before moving on to other assessment techniques.
Choice D rationale: Light palpation is often the initial step in the abdominal assessment sequence, followed by auscultation.

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A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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