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","C","D"]

Explanation

Choice A rationale:

Proper nutrition with adequate protein and vitamin C is essential for wound healing as these nutrients are needed for collagen synthesis.

Choice B rationale:

Resting as much as possible and keeping the incisional area still may not necessarily aid in healing. Movement can actually promote circulation and healing.

Choice C rationale:

Increasing fluid intake to at least 4000 mL per day can help keep the body hydrated, which is beneficial for wound healing.

Choice D rationale:

Keeping skin and surrounding tissue clean and dry can help prevent infection, which can delay wound healing.

Choice E rationale:

Exercise and deep breathing can increase oxygenation, which is beneficial for wound healing.

A. Keep the wound dry. B. Help destroy microorganisms in an infected wound. C. Leave the dressing in place for 10 days. D. Occlude air and promote breakdown of necrotic tissue.

Correct Answer is D

Explanation

Choice A rationale:

Hydrocolloid dressings do not keep the wound dry; they maintain a moist environment.

Choice B rationale:

These dressings do not have antimicrobial properties.

Choice C rationale:

While these dressings can be left in place for several days, it is not their major purpose.

Choice D rationale:

Hydrocolloid dressings occlude air and promote autolytic debridement of necrotic tissue.

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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

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

Correct Answer is ["A","C","D"]

Explanation

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

Correct Answer is D

Explanation

The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

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:

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

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

Superficial wounds heal faster when kept:

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.