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
A patient has a pressure injury with full-thickness tissue loss, visible slough covering the wound bed, and undermining present. Which stage is this?
Answer: Unstageable
When slough or eschar obscures the wound base so depth cannot be determined, the injury is classified as unstageable.
Which dressing type is BEST suited for a heavily exudating wound to maintain a moist environment without causing maceration?
Answer: Alginate
Alginate dressings are highly absorbent and ideal for heavily exudating wounds while still maintaining a moist wound environment.
A patient is repositioned every 2 hours, but a stage 1 pressure injury develops over the sacrum. What is the MOST appropriate next intervention?
Answer: Apply a pressure-redistributing foam dressing
A pressure-redistributing foam dressing reduces focal pressure and shear, helping to prevent progression of a stage 1 injury.
When documenting wound measurements, the LPN records length as 4 cm, width as 3 cm, and depth as 1.5 cm. Which measurement technique is standard?
Answer: Length = head to toe axis; width = side to side
Standard wound measurement uses the head-to-toe axis for length and the side-to-side (perpendicular) axis for width.
A resident in a long-term care facility has a deep tissue pressure injury (DTPI). Which description BEST matches this classification?
Answer: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration
DTPI presents as persistent non-blanchable deep red, maroon, or purple discoloration reflecting injury to underlying soft tissue.
Which intervention is CONTRAINDICATED when caring for a stage 1 pressure injury?
Answer: Massaging the erythematous area
Massaging over a reddened bony prominence can further damage fragile capillaries and worsen tissue injury.
An LPN is assessing a wound with yellow, stringy tissue firmly adherent to the wound bed. This tissue is BEST described as:
Answer: Slough
Slough is yellow, tan, or white soft necrotic tissue that may be stringy or adherent to the wound bed.