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 B
Explanation
Choice A rationale:
Refraining from touching the drainage spout with the hand is a correct practice. This helps to prevent contamination of the drain.
Choice B rationale:
Using one alcohol wipe to clean both the spout and the plug is incorrect. Each part should be cleaned with a separate alcohol wipe to prevent cross-contamination.
Choice C rationale:
Pointing the device away from oneself while opening it is a correct practice. This helps to prevent accidental exposure to the drainage fluid.
Choice D rationale:
Compressing the device in the hand before closing is a correct practice. This helps to maintain the suction in the drain.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Leaving nonbleeding wounds open to air increases the risk of infection and delayed healing. Wounds need a moist environment to promote cell migration and collagen synthesis, essential for the initial inflammatory phase of healing.
Choice B rationale: Corticosteroids suppress the immune response and inflammation, which can delay wound healing. They inhibit leukocyte migration and fibroblast proliferation, which are crucial during the initial stage of the healing process.
Choice C rationale: Mechanical debridement is typically used for chronic wounds with necrotic tissue. In the initial stage of wound healing, it is not necessary and could damage newly formed tissue, delaying the healing process.
Choice D rationale: Oxygen therapy at 2L/min via nasal cannula enhances tissue oxygenation, promoting cellular activities such as collagen synthesis, angiogenesis, and leukocyte function, which are critical during the initial inflammatory phase of wound healing.
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