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 B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

A. Numbing the area treated. B. Dilating the blood vessels. C. Drawing fluid to the site of application. D. Constricting the blood vessels.

Correct Answer is B

Explanation

Choice A rationale:

Numbing the area treated is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.

Choice B rationale:

Dilating the blood vessels is the correct answer. Moist heat therapy works by increasing the temperature of the skin/soft tissue, which leads to vasodilation and increased blood flow to the treated area.

Choice C rationale:

Drawing fluid to the site of application is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.

Choice D rationale:

Constricting the blood vessels is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area through vasodilation.

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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 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:

Correct Answer is B

Explanation

Moist heat has the physiological effect of:

Correct Answer is B

Explanation

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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.