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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Irrigating with sterile saline before swabbing can dilute the wound specimen and reduce the accuracy of the culture results. This is because the saline can wash away some of the bacteria that are present in the wound, making it more difficult to identify the specific bacteria that are causing the infection.
Additionally, swabbing the center of the wound may not collect a representative sample of the bacteria present, as bacteria can often be found in higher concentrations at the edges of the wound. This is because the edges of the wound are often where the tissue is most damaged and where the bacteria are able to enter the body more easily.
Choice B rationale:
Obtaining a sample of the drainage from the dressing on the wound may not be as accurate as collecting a sample directly from the wound. This is because the drainage may contain bacteria from the surrounding skin or environment, which could contaminate the culture results.
Additionally, the drainage may not contain a representative sample of the bacteria present in the wound, as some bacteria may not be able to drain out of the wound.
Choice D rationale:
Collecting a tissue sample from the wound during a surgical procedure is the most accurate way to obtain a culture. However, this is not always feasible or necessary.
It is often possible to obtain an accurate culture by collecting a sample from the wound using a sterile swab. This is a less invasive procedure and can be done at the bedside.
Correct Answer is D
Explanation
Choice A rationale:
Soaking the wound in an Epsom salt solution is not recommended for abscessed wounds. While Epsom salt has some potential benefits for wound healing, such as reducing inflammation and drawing out fluids, it can also be irritating to the skin and may actually worsen the abscess. Additionally, there's a risk of introducing bacteria from the Epsom salt into the wound, which could lead to further infection.
Choice B rationale:
Administering warm water sitz baths is not directly applicable to an abscessed leg wound. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or postpartum discomfort. They may help to soothe and cleanse the affected area, but they would not be effective in treating an abscess on the leg.
Choice C rationale:
Applying cold moist compresses is not the most appropriate intervention for an abscessed wound. Cold compresses can help to reduce pain and inflammation, but they can also constrict blood vessels and potentially hinder the healing process. Warm compresses are generally preferred for abscesses because they can help to promote drainage and healing.
Choice D rationale:
Applying warm moist compresses is the most appropriate nursing intervention for an abscessed leg wound. Warm compresses have several beneficial effects:
They promote vasodilation, which increases blood flow to the area and helps to deliver white blood cells and other healing agents to the site of infection.
They help to soften and loosen hardened pus, making it easier for the abscess to drain.
They provide a moist environment that promotes healing and prevents the wound from drying out. They can help to reduce pain and inflammation.
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