LPN Wound Care and Pressure Injury Staging 2

Question 1

A patient has a pressure injury with full-thickness tissue loss, visible slough covering the wound bed, and undermining present. Which stage is this?

Accepted Answer

Unstageable

Answer

When slough or eschar obscures the wound base so depth cannot be determined, the injury is classified as unstageable.

Question 2

Which dressing type is BEST suited for a heavily exudating wound to maintain a moist environment without causing maceration?

Accepted Answer

Alginate

Answer

Alginate dressings are highly absorbent and ideal for heavily exudating wounds while still maintaining a moist wound environment.

Question 3

A patient is repositioned every 2 hours, but a stage 1 pressure injury develops over the sacrum. What is the MOST appropriate next intervention?

Accepted Answer

Apply a pressure-redistributing foam dressing

Answer

A pressure-redistributing foam dressing reduces focal pressure and shear, helping to prevent progression of a stage 1 injury.

Question 4

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?

Accepted Answer

Length = head to toe axis; width = side to side

Answer

Standard wound measurement uses the head-to-toe axis for length and the side-to-side (perpendicular) axis for width.

Question 5

A resident in a long-term care facility has a deep tissue pressure injury (DTPI). Which description BEST matches this classification?

Accepted Answer

Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration

Answer

DTPI presents as persistent non-blanchable deep red, maroon, or purple discoloration reflecting injury to underlying soft tissue.

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