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The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?

Surgical debridement of the wound

Increased drainage from the wound

Documenting the wound status daily

Increased monitoring of the wound condition

Answer and Explanation

The Correct Answer is A

Choice A rationale

A black pressure ulcer indicates necrotic tissue, which often requires surgical debridement.

Choice B rationale

Increased drainage from the wound is not typically associated with a black pressure ulcer.

Choice C rationale

While documenting the wound status daily is part of wound care, it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.

Choice D rationale

Increased monitoring of the wound condition is part of wound care, but it is not a specific event anticipated when planning care for a patient with a black pressure ulcer.

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Correct Answer is C

Explanation

Choice A rationale

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

Choice B rationale

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

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

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

Correct Answer is ["31"]

Explanation

Step 1: Calculate the total volume to be infused. Total volume = 250 mL.

Step 2: Calculate the total time for the infusion in minutes. Total time = 2 hours × 60 minutes/hour = 120 minutes.

Step 3: Calculate the flow rate in mL/min. Flow rate = Total volume ÷ Total time = 250 mL ÷ 120 min = 2.08 mL/min.

Step 4: Calculate the flow rate in drops/min. Flow rate = 2.08 mL/min × 15 drops/mL = 31.25 drops/min. So, the nurse should adjust the flow rate to deliver approximately 31 drops per minute.

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The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Correct Answer is C

Explanation

A nurse is preparing to infuse a 250-mL unit of packed red blood cells (RBCs) over 2 hours. The drop factor of the manual intravenous (IV) tubing is 15 drops/mL. How many drops per minute should the nurse adjust the flow rate to deliver?

Correct Answer is ["31"]

Explanation

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