The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.
Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Stage 1.

Stage 3.

Stage 2.

Stage 4.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

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Correct Answer is B

Explanation

Choice A rationale:

Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice B rationale:

Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.

Choice C rationale:

Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice D rationale:

Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

A. A client who is unresponsive to verbal commands and changes position occasionally. B. A client who is alert and responsive and eats 25% of each meal. C. A client who makes frequent slight changes in position and walks occasionally. D. A client who is receiving enteral feeding and can change position independently.

Correct Answer is A

Explanation

Choice A rationale:

An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.

Choice B rationale:

A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.

Choice D rationale:

A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.

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The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

Correct Answer is B

Explanation

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is A

Explanation

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

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?

A nurse is collecting data on a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

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

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

What type of wound heals by delaying the suturing until the infection is resolved?

Chronic wounds that are not healing well may benefit from (Select all that apply.)

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.
Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.