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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 B

Explanation

Choice A rationale:

Documentation is important but not the first priority.

Choice B rationale:

Assessing the patient for any complaints or problems in the wound area is the first priority in NPWT treatment.

Choice C rationale:

Checking the setting on the NPWT unit is important but comes after assessing the patient.

Choice D rationale:

Observing the dressing area when assessing vital signs is part of the assessment process but not the first priority.

A. The patient has to be repositioned for the bed to be changed. B. Shearing is more likely from wet sheets. C. The moisture creates an environment suitable for the growth of microorganisms in a wound. D. Greater pressure is exerted by a wet bed.

Correct Answer is C

Explanation

Choice A rationale:

Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.

Choice B rationale:

While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.

Choice C rationale:

Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.

Choice D rationale:

A wet bed does not exert greater pressure on the patient’s 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

The patient is undergoing NPWT treatment for wound healing.Which would be your first priority in caring for this patient?

Correct Answer is B

Explanation

A patient is incontinent the first day after his surgery.This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:

Correct Answer is C

Explanation

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When applying an ice pack, it is necessary to:

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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: