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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:

Reconstruction is incorrect because it is not the second stage of wound healing.

Choice B rationale:

Maturation is incorrect because it is not the second stage of wound healing.

Choice C rationale:

Proliferation is incorrect because it is not the second stage of wound healing.

Choice D rationale:

Inflammation is the correct answer because it is the second stage of wound healing.

A. Leave it until the end of the shift. B. Remove the drain. C. Empty the reservoir. D. Notify the surgeon about the blood loss.

Correct Answer is C

Explanation

Choice A rationale:

Leaving the reservoir until the end of the shift could lead to overfilling and ineffective drainage.

Choice B rationale:

Removing the drain is not within the nurse’s scope of practice and could lead to complications.

Choice C rationale:

Emptying the reservoir ensures effective drainage and allows for accurate measurement of output.

Choice D rationale:

Notifying the surgeon about the blood loss may be necessary if the amount is significant, but it is not the immediate action.

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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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Enter instructional text.The nurse clarifies that the second stage of wound healing is:

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

Many factors aid healing.You assist the patient to specifically improve his healing ability by encouraging (Select all that apply.)

The nurse assesses the large raised scar on the African American patient.The nurse documents the lesion as a:

When preparing to change a sterile dressing over an incision, it is most important to remember to:

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

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

The nurse places Dakin solution in a wound to accomplish chemical:

When applying an ice pack, it is necessary to:

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 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.