The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.
He states that it is painful.
This is a:

pressure injury.

stage 2.

stage 1.

stage 3.

stage 4. .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

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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. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle. B. Double bag the dressing, label it "biohazard," and send it for decontamination. C. Place the dressing in a biohazardous waste container. D. Discard the dressing in the bedside trash receptacle.

Correct Answer is C

Explanation

Choice A rationale:

Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

Choice B rationale:

Double bagging the dressing, labeling it “biohazard,” and sending it for decontamination is incorrect because it is not the standard procedure for disposing of soiled dressings.

Choice C rationale:

Placing the dressing in a biohazardous waste container is the correct method for disposing of soiled dressings.

Choice D rationale:

Discarding the dressing in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.

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The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

Nursing Test Bank

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 removing a wound dressing that is saturated with blood and purulent drainage.Which of the following methods should the nurse use when disposing of the soiled dressing?

Correct Answer is C

Explanation

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

When changing the dressing on the patient's right arm, you see that the dressing has a moist yellow-red stain on it. You would document this as drainage.

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

A nurse is ambulating a patient in the hall a few days after abdominal surgery, and the patient says, "I think something just let go.”. The initial intervention by the nurse should be to:

A 28-year-old male is a patient at your clinic.He states that he had a minor accident with his motorcycle 5 days ago.He sustained several scrapes and wounds.The wound on his calf has a pinkish-red center area that looks bumpy.This indicates that the wound is:

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.
He states that it is painful.
This is a: