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.
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.
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 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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