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The nurse on the unit is going to perform wound care for her patient.
After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

stage 3.

stage 2.

stage 4.

stage 1.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

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Correct Answer is D

Explanation

Choice A rationale:

Karaya paste is used for ostomy care, not for dressing changes.

Choice B rationale:

Paper tape might not provide the necessary adhesion for frequent dressing changes.

Choice C rationale:

Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.

Choice D rationale:

Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.

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 on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

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Naxlex Comprehensive Predictor Exams

Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal.The nurse would change the dressing procedure in order to use:

Correct Answer is D

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 planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

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 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.

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

A patient who underwent removal of a breast must be discharged home with a Jackson-Pratt wound drain in place.As the patient demonstrates the procedure for emptying it, the nurse should correct her if she:

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

The nurse on the unit is going to perform wound care for her patient.
After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.