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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:

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.

A. Full thickness skin loss with visible adipose tissue. B. Full thickness skin loss with visible bone. C. Intact skin with localized erythema. D. Partial-thickness skin loss with red tissue in the wound bed.

Correct Answer is C

Explanation

Choice A rationale:

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

Choice B rationale:

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

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

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

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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

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

Correct Answer is D

Explanation

A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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

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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.

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.