Wound Care and Pressure Injury Staging Flashcards
7 cards from real LPN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Wound Care and Pressure Injury Staging flashcards as text
An LPN is assessing a client's pressure injury over the sacrum. The wound bed shows full-thickness tissue loss with visible subcutaneous fat, but bone, tendon, and muscle are not exposed. How should the LPN stage this injury?
Answer: Stage 3
A Stage 3 pressure injury is defined as full-thickness skin and tissue loss where adipose (fat) is visible in the ulcer, but bone, tendon, or muscle are not exposed. Slough or eschar may be present but do not obscure the depth of tissue loss. This stage represents a deep crater.
A client has an area of intact skin on the heel that is red and does not blanch when pressed. The LPN would document this finding as which stage of pressure injury?
Answer: Stage 1
A Stage 1 pressure injury is characterized by intact skin with a localized area of non-blanchable erythema (redness). The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. This indicates underlying tissue damage from pressure.
An LPN is preparing to irrigate a client's surgical wound. Which technique demonstrates proper procedure?
Answer: Directing the flow of solution from the top to the bottom of the wound.
Wound irrigation should always proceed from the least contaminated area to the most contaminated area to prevent spreading microorganisms into cleaner parts of the wound. This is often described as cleaning from 'clean to dirty' or from the center of the wound outward.
A pressure injury on a client's coccyx is completely covered by hard, dry, black eschar. How should this wound be staged?
Answer: Unstageable
An unstageable pressure injury is characterized by full-thickness skin and tissue loss in which the extent of the damage cannot be confirmed because it is obscured by slough or eschar. The eschar must be removed to expose the base of the wound before it can be accurately staged.
An LPN is contributing to the plan of care for an immobile client at high risk for developing pressure injuries. What is a priority nursing intervention?
Answer: Repositioning the client at least every 2 hours.
Repositioning is a critical intervention to relieve pressure over bony prominences and restore blood flow to the tissues. A turning schedule of at least every 2 hours is the standard of care for preventing pressure injury development in at-risk, immobile clients.
An LPN assesses a pressure injury that presents as a shallow open ulcer with a red-pink wound bed, without slough. It also looks like an intact, serum-filled blister. This describes which stage?
Answer: Stage 2
A Stage 2 pressure injury involves partial-thickness loss of the dermis. It presents as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured serum-filled blister. There is no slough or bruising present.
An LPN is caring for a client with a suspected deep tissue injury (DTI) over the left trochanter. What clinical finding is consistent with this diagnosis?
Answer: A purple, localized area of discolored intact skin.
A deep tissue injury is a pressure-related injury to subcutaneous tissues under intact skin. It typically presents as a persistent, non-blanchable purple or maroon localized area of discolored intact skin or a blood-filled blister. The area may be preceded by tissue that is painful, firm, or boggy.