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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale:
An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.
Choice B rationale:
A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.
Choice D rationale:
A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.
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