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 C

Explanation

Choice A rationale:

Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.

Choice B rationale:

Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.

A. Supine with the head tilted toward the right eye. B. Upright with the head tilted toward the left eye. C. Upright with the head hyperextended. D. Supine with the head hyperextended.

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.

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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 is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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

Correct Answer is A

Explanation

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:

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

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

A nurse is caring for a client who is at risk for a pressure injury.Which of the following actions should the nurse take?

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding.Which of the following types of dressings should the nurse select to help promote hemostasis?

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:

The nurse places Dakin solution in a wound to accomplish chemical:

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

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.