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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 B

Explanation

Choice A rationale:

Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice B rationale:

Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.

Choice C rationale:

Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice D rationale:

Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

A. applying hydrocolloids to the wound bed. B. placing a transparent dressing over the pressure injury. C. pulsating lavage. D. using a topical enzyme solution in the wound bed.

Correct Answer is C

Explanation

Choice A rationale:

Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.

Choice B rationale:

Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.

Choice C rationale:

Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.

Choice D rationale:

Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement.Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Correct Answer is C

Explanation

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Moist heat has the physiological effect of:

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

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

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.