Author Question: A patient has a pressure ulcer that is covered with black and brown eschar. The nurse would document ... (Read 54 times)

Yi-Chen · **on:** Jul 22, 2018

A patient has a pressure ulcer that is covered with black and brown eschar. The nurse would document the stage of this wound as being:

a. Stage 1 c. Stage 4
b. Stage 2 d. Unstageable

Question 2

The nurse is to change a patient's dressing after surgery. This type of nursing intervention is classified as which of the following?

a. activities of daily living c. teaching
b. therapeutic interven-tion d. discharge planning

ciecieme · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Stage 1 has intact skin with nonblanchable areas of redness. Stage 2 wounds are partial thickness loss of dermis with a shallow open ulcer and red or pink wound bed. Stage 4 ulcers are full thickness tissue loss with exposed bone, tendon, or muscle. Unstageable wounds are covered with slough or eschar in the wound bed. The eschar has to be removed before the wound can be correctly staged.

Answer to Question 2

B
Therapeutic interventions are those measures directed toward resolution of a current problem and include activities such as administering medications and treatments. Written orders must be verified before implementing interventions requiring prescriptive authority.