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The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
You would document this wound as:

stage 1.

unstageable.

deep tissue injury.

stage 2.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

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Correct Answer is A

Explanation

Choice A rationale:

Superficial wounds heal faster when kept moist.

Choice B rationale:

Wet-to-dry dressings are not typically used for superficial wounds as they can cause trauma to the wound bed during removal.

Choice C rationale:

Occlusion can help maintain a moist environment, but it’s not the only factor in wound healing.

Choice D rationale:

Debridement is the removal of dead or infected tissue from a wound, which can promote healing, but it’s not the only factor.

A. stage 3. B. stage 2. C. stage 4. D. stage 1.

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.

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The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.You would document this wound as:

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Naxlex Comprehensive Predictor Exams

Superficial wounds heal faster when kept:

Correct Answer is A

Explanation

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.

Correct Answer is C

Explanation

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

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The patient has an area over the sacrum that is reddened around the edges with a blackened area in the center.
You would document this wound as: