The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?

Stage 1

Stage 2

Stage 3

Stage 4

Answer and Explanation

The Correct Answer is B

Choice A rationale
Stage 1 wounds are characterized by non-blanchable redness of intact skin. The presence of partial-thickness skin loss indicates that the wound has progressed beyond stage 1, making this choice incorrect.

Choice B rationale
Stage 2 wounds involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This description matches the nurse’s assessment of the patient’s wound, confirming that it is indeed a stage 2 wound.

Choice C rationale
Stage 3 wounds exhibit full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. The patient’s wound, with partial-thickness skin loss and no mention of exposed subcutaneous structures, does not fit the criteria for stage 3.

Choice D rationale
Stage 4 wounds involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The patient’s wound does not have these characteristics, ruling out stage 4.

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Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula is not typically indicated in the initial stage of wound healing. Oxygen therapy is used for clients with respiratory distress or hypoxia, not as a standard wound care procedure.

Choice B rationale
Mechanical debridement is a method used to remove dead tissue from wounds, but it is not usually part of the initial wound care plan. Debridement is considered when there is necrotic tissue present that may impede healing.

Choice C rationale
Leaving non-bleeding wounds open to air can be beneficial during the initial stage of wound healing. Exposure to air can help to dry out the wound and prevent maceration of the surrounding skin. It also allows for the observation of the wound and easy access for dressing changes if needed.

Choice D rationale
Administering a corticosteroid medication is not a standard part of initial wound care. Corticosteroids can actually delay wound healing and are generally avoided unless there is a specific indication, such as an inflammatory skin condition.

A. Moist B. Dry C. Covered with a wet-to-dry dressing D. Debrided

Correct Answer is A

Explanation

Choice A rationale
Keeping a superficial wound moist can promote faster healing. A moist environment helps to protect the new tissue, prevent the wound from drying out and forming a scab, which can slow down the healing process. It also allows cells to move across the wound more easily, which can speed up healing.

Choice B rationale
While it was once common practice to keep wounds dry, research has shown that a dry environment can actually slow down the healing process by causing cells to dehydrate and scabs to form, which can impede the growth of new tissue.

Choice C rationale
A wet-to-dry dressing is typically used for mechanical debridement and not for the purpose of speeding up healing. This type of dressing can be useful for removing dead tissue but is not necessarily conducive to the fastest healing of superficial wounds.

Choice D rationale
Debridement is the removal of dead or infected tissue from a wound to help healing. While it is an important part of wound care, the act of debridement itself does not speed up healing; rather, it sets the stage for it by cleaning the wound.

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The nurse is caring for a 48-year-old female patient with diabetes mellitus (DM), hypertension (HTN), and limited mobility. Upon assessment, she notes that there is a pink, viable wound bed with partial-thickness skin loss. Which stage of wound healing does this describe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Correct Answer is C

Explanation

Superficial wounds heal faster when kept:

Correct Answer is A

Explanation

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