Which term should a nurse use to describe a deep decubitus ulcer on a patient’s heel that is covered in thick necrotic tissue?

Indurated

Fluctuant

Unstageable

Macerated

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Indurated describes tissue that is hardened and thickened, typically due to inflammation or fibrosis. While a decubitus ulcer with thick necrotic tissue may feel firm to the touch, induration does not accurately capture the extent of tissue damage and depth of the wound.

Indurated tissue often feels leathery or stiff, while necrotic tissue can be more varied in texture, ranging from dry and crusty to soft and sloughy.

Additionally, induration can occur in wounds that are not full-thickness ulcers, such as pressure injuries that have not yet progressed to the point of tissue loss.

Choice B rationale:

Fluctuant describes a fluid-filled cavity beneath the skin. While a decubitus ulcer with thick necrotic tissue may have some underlying fluid, it would not typically be described as fluctuant.

Fluctuance is more characteristic of abscesses or other fluid collections that have a distinct, palpable pocket of fluid.

The presence of thick necrotic tissue in a decubitus ulcer can obscure the presence of any underlying fluid, making it difficult to assess for fluctuance.

Choice D rationale:

Macerated describes skin that is softened and broken down due to prolonged exposure to moisture. While maceration can occur in the surrounding skin of a decubitus ulcer, it does not accurately describe the ulcer itself.

Maceration is typically seen in areas where skin folds rub together, such as the groin or armpits, and is often associated with incontinence or excessive sweating.

The presence of thick necrotic tissue in a decubitus ulcer indicates a more advanced stage of tissue damage that is not simply due to moisture exposure.

Choice C rationale:

Unstageable is the most accurate term to describe a decubitus ulcer with thick necrotic tissue because it indicates that the extent of tissue damage cannot be fully assessed.

Thick necrotic tissue obscures the base of the wound and the surrounding tissue, making it impossible to determine the depth of the ulcer or the extent of undermining.

This lack of visibility prevents accurate staging of the ulcer using the traditional pressure ulcer staging system, which categorizes ulcers based on their depth and extent of tissue involvement.

Therefore, unstageable is the most appropriate term to describe a decubitus ulcer with thick necrotic tissue.

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Correct Answer is C

Explanation

Choice A rationale:

Burning dried herbs is a form of traditional medicine, not allopathic medicine.

Traditional medicine encompasses a wide range of practices and therapies that have been used for centuries across different cultures.

It often relies on natural substances and processes, such as herbs, acupuncture, and massage, to promote healing and well- being.

While traditional medicine can offer valuable benefits, it's important to note that it's not always based on scientific evidence and its efficacy can vary depending on the specific practice and condition being treated.

Choice B rationale:

Tai chi exercises are a form of complementary and alternative medicine (CAM), not allopathic medicine.

CAM encompasses a diverse group of therapies that are not considered part of mainstream conventional medicine. Tai chi is a mind-body practice that involves gentle, flowing movements and deep breathing.

It has been shown to offer a range of health benefits, including reducing stress, improving balance, and easing pain.

However, it's important to note that tai chi is not a cure-all and should not be used as a substitute for conventional medical care when necessary.

Choice C rationale:

Prescription of antibiotic medication is a hallmark of allopathic medicine.

Allopathic medicine, also known as conventional or Western medicine, is based on the scientific understanding of the body and disease.

It focuses on diagnosing and treating specific diseases or conditions using medications, surgery, or other interventions that have been proven effective through rigorous scientific research.

Antibiotics are a type of medication that specifically targets and kills bacteria.

They are essential for treating bacterial infections, which can cause a wide range of illnesses, from minor skin infections to life- threatening pneumonia.

Choice D rationale:

Manipulation of the spine, also known as chiropractic care, is a form of CAM, not allopathic medicine. Chiropractic care focuses on the musculoskeletal system, particularly the spine.

Chiropractors use manual adjustments to the spine to relieve pain, improve range of motion, and restore function.

While some studies have shown that chiropractic care can be effective for certain conditions, such as lower back pain, it's important to note that it's not a cure-all and should not be used as a substitute for conventional medical care when necessary.

A. The nurse aspirates immediately prior to injecting the medication. B. The nurse gently massages the injection site immediately afterward. C. The nurse draws up the medication into a 1-mL syringe with a 32-gauge needle. D. The nurse injects the medication into the soft tissue of the patient’s abdomen.

Correct Answer is D

Explanation

Choice A rationale:

Aspirating prior to injecting enoxaparin is not recommended.

Aspiration was once a common practice to check if a needle had entered a blood vessel.

However, research has shown that aspiration is not necessary for subcutaneous injections and may even be harmful. It can cause pain, bruising, and hematoma formation.

Additionally, aspirating can increase the risk of needlestick injuries.

For these reasons, aspiration is no longer recommended for subcutaneous injections of enoxaparin or other anticoagulants.

Choice B rationale:

Massaging the injection site after administering enoxaparin is not recommended. Massaging can increase the risk of bruising and hematoma formation.

It can also cause the medication to be absorbed too quickly, which can increase the risk of bleeding.

The best practice is to apply gentle pressure to the injection site with a dry gauze pad for a few seconds after the injection. This will help to prevent bleeding and bruising.

Choice C rationale:

The size of the syringe and needle used to administer enoxaparin is not specified in the question. However, a 1-mL syringe with a 32-gauge needle is a common choice for subcutaneous injections.

This size syringe is small enough to be easy to handle, and the 32-gauge needle is thin enough to minimize discomfort.

Choice D rationale:

The abdomen is the preferred site for subcutaneous injections of enoxaparin.

The abdomen has a large surface area of soft tissue, which makes it easy to inject the medication.

The abdomen is also relatively free of blood vessels and nerves, which reduces the risk of bruising, bleeding, and pain. Other potential injection sites for enoxaparin include the upper arms, thighs, and buttocks.

However, the abdomen is generally the preferred site.

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Which term should a nurse use to describe a deep decubitus ulcer on a patient’s heel that is covered in thick necrotic tissue?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the Nursing Exam #3 (Winter 2023), which of the following is an example of allopathic treatment?

Correct Answer is C

Explanation

The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct?

Correct Answer is D

Explanation

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