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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A:
This is the correct choice. The Jackson-Pratt drain incorporates a flexible bulb that aspirates drainage from the wound by self-suction. When the reservoir is half full, the suction pressure is diminished. Thus it is appropriate to empty it and record the amount of drainage you discard.
Choice B:
While it's important to keep the surgeon informed about the patient's condition, in this case, the purpose of the Jackson-Pratt drain is to aspirate drainage, such as excess blood, from the wound. Many factors are involved in determining what an acceptable amount of drainage is; however, excessive blood loss that must be reported is likely to affect the patient's vital signs.
Choice C:
The surgeon determines when to remove the drain, and in most cases, a patent and functioning drain remains in place for a few days.
Choice D:
Leaving the reservoir half full until the end of the shift is not recommended. The suction pressure is diminished when the reservoir is half full, which could affect the drain's effectiveness.
Correct Answer is D
Explanation
Choice A rationale
A headache is a nonspecific symptom and can be associated with many conditions. It is not typically indicative of internal hemorrhage, which is more likely to present with hemodynamic changes.
Choice B rationale
While a rising pulse is a sign of internal hemorrhage due to the body’s attempt to maintain cardiac output, the blood pressure would typically fall, not rise, as the blood volume decreases.
Choice C rationale
Lethargy and a falling pulse are signs of decreased cardiac output, but in the case of internal hemorrhage, the blood pressure would usually fall, not rise, due to the loss of blood volume.
Choice D rationale
Restlessness, a rising pulse, and falling blood pressure are classic signs of internal hemorrhage. The body responds to blood loss by increasing heart rate to maintain perfusion, but as volume continues to decrease, blood pressure falls.
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