Author Question: In a patient with a stage II pressure ulcer, the nurse describes the wound as: a. superficial ... (Read 111 times)

student77 · **on:** Jul 24, 2018

In a patient with a stage II pressure ulcer, the nurse describes the wound as:

a. superficial blistering.
b. nonblanchable redness.
c. loss of skin without bone exposure.
d. loss of skin with exposed muscle.

Question 2

A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers supplies to prepare the sterile field using a packaged drape. Which option correctly describes how the nurse should set up the field?

a. Don sterile gloves before opening the packaged drape.
b. Clean the bottle of irrigation solution with alcohol before placing the bottle on the field.
c. Avoid dropping sterile supplies close to the 1-inch border around the drape.
d. Leave the sterile field unattended to obtain needed supplies.

momolu · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

A
A stage II pressure ulcer is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed, without slough. It also may present as an intact or open/ruptured serum-filled blister. It usually presents as a shiny or dry shallow ulcer without sloughing or bruising. The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage III pressure ulcers involve full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed.

Answer to Question 2

C
The exterior border of the sterile drape is presumed contaminated, so all supplies must be kept within the sterile portion. Dropping supplies too close to the 1-inch border risks having them bounce off the sterile area. Nonsterile supplies are never to be placed on the sterile field. The sterile field is never to be out of the nurse's line of sight. Sterile gloves will not be applied until the sterile field is set up, and items needed to deliver care are ready for use. Applying them earlier in the process risks having them become contaminated.