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:

Dakin’s solution is used for chemical debridement, which involves the use of a chemical, such as Dakin’s solution, to break down and remove dead tissue.

Choice B rationale:

Primary intention is a term used to describe the healing of a clean wound without tissue loss. Dakin’s solution does not directly contribute to this process.

Choice C rationale:

While Dakin’s solution can aid in the healing process by preventing and treating infections, it does not directly cause healing.

Choice D rationale:

Phagocytosis is a process carried out by certain cells in the body to engulf and destroy pathogens or debris. Dakin’s solution does not perform this function.

A. Hydrogel dressing. B. Polymeric membrane dressing. C. Hydrofiber dressing. D. Hydrocolloid dressing.

Correct Answer is C

Explanation

Choice A rationale:

Hydrogel dressings are used for wounds with little to no exudate. They are not suitable for wounds with significant exudate.

Choice B rationale:

Polymeric membrane dressings are used for dry wounds with or without depth. They are not suitable for wounds with significant exudate.

Choice C rationale:

Hydrofiber dressings are used for wounds with moderate to high amounts of exudate. They are suitable for wounds with significant exudate.

Choice D rationale:

Hydrocolloid dressings are used for wounds that have minimal to moderate exudate. They are not suitable for wounds with significant exudate.

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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 places Dakin solution in a wound to accomplish chemical:

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has an infected wound with significant exudate.Which of the following dressings should the nurse plan to cover the client's wound?

Correct Answer is C

Explanation

A nurse explains that the major purpose of the use of a hydrocolloid dressing is to:

A patient has a pooling of blood under unbroken skin of the hip after a fall.The nurse should document that this patient has a(n):

Moist heat has the physiological effect of:

When preparing to change a sterile dressing over an incision, it is most important to remember to:

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

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

Safety factors involved in using an Aquathermia pad unit for a patient include (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.