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:

Testing the temperature of the solution is crucial to prevent burns.

Choice B rationale:

While using sterile equipment and solution is important, it’s not the most important in a hot soak treatment.

Choice C rationale:

Comfort is important but not as critical as preventing burns.

Choice D rationale:

Soaking only the affected area is good practice but not as vital as preventing burns.

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.

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Naxlex Comprehensive Predictor Exams

When giving a hot soak treatment, it is most important to:

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 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?

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

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

When applying an ice pack, it is necessary to:

Enter instructional text.The nurse clarifies that the second stage of wound healing is:

A nurse is assessing a surgical patient for internal hemorrhage, which would be indicated by:

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.