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 A

Explanation

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

A. Using a thermometer to check the temperature of the pad. B. Securing the pad to the patient. C. Assisting the patient to lie on top of the pad. D. Instructing the patient not to sleep on the pad. E. Inspecting the plug and cord for cracks or fraying.

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

Explanation

E. Using a thermometer to check the temperature of the pad, Securing the pad to the patient, Instructing the patient not to sleep on the pad, Inspecting the plug and cord for cracks or fraying.

Choice A rationale:

It’s important to check the temperature of the pad to prevent burns.

Choice B rationale:

Securing the pad ensures it stays in place and provides consistent heat.

Choice C rationale:

Patients should not lie on top of the pad as it can lead to burns.

Choice D rationale:

Patients should not sleep on the pad to prevent prolonged exposure which can lead to burns.

Choice E rationale:

Inspecting the plug and cord prevents electrical hazards.

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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

A nurse performing a right eye irrigation will position the patient:

Correct Answer is A

Explanation

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

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

Explanation

The nurse is taking care of a postsurgical patient and notes the incision is clean and dry, with sutures intact.The nurse further assesses that the wound is healing by:

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

The nurse is performing a dry sterile dressing change for an abdominal wound.The nurse should use a swab to clean:

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

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

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

When applying an ice pack, it is necessary to:

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

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.