Author Question: The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After ... (Read 51 times)

jjjetplane · **on:** Jul 23, 2018

The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should:

1. Obtain a transparent dressing for the UAP to place on the wound.
2. Request a consult with the wound care nurse.
3. Cleanse the wound and apply a dressing.
4. Tell the UAP to reevaluate the wound in 20 minutes.

Question 2

The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center.

Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?
1. There is undermining of adjacent tissues.
2. The crater extends into the subcutaneous tissue.
3. The joint capsule of the hip is visible.
4. The ulcer has thick dark eschar over the top.

Question 3

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure.

One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?
1. Reactive hyperemia
2. Stage I pressure ulcer
3. Stage II pressure ulcer
4. Stage III pressure ulcer

sylvia · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1: The UAP is not educationally prepared to dress the wound.
Rationale 2: At this point a consult with the wound care nurse is not required.
Rationale 3: The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing.
Rationale 4: The UAP is not educationally prepared to evaluate the wound.

Answer to Question 2

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Answer to Question 3

Correct Answer: 1
Rationale: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred. Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time. Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters. Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.