LPN Wound Care and Pressure Injury Staging 2 — Questions and Answers
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?
- Stage 2
- Stage 3
- Stage 4
- Unstageable (Correct answer)
Correct answer: Unstageable
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?
- Hydrocolloid
- Alginate (Correct answer)
- Transparent film
- Dry gauze
Correct answer: Alginate
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?
- Massage the reddened area vigorously
- Apply a pressure-redistributing foam dressing (Correct answer)
- Increase repositioning to every 30 minutes
- Apply a wet-to-dry dressing
Correct 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.
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?
- Length = head to toe axis; width = side to side (Correct answer)
- Length = shortest dimension; width = longest dimension
- Length = wound circumference; width = wound area
- Length = side to side; width = head to toe axis
Correct 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.
Question 5: A resident in a long-term care facility has a deep tissue pressure injury (DTPI). Which description BEST matches this classification?
- Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration (Correct answer)
- Partial-thickness loss of skin with exposed dermis
- Full-thickness skin and tissue loss with visible fascia
- Non-blanchable erythema of intact skin
Correct 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.
Question 6: Which intervention is CONTRAINDICATED when caring for a stage 1 pressure injury?
- Applying a transparent film dressing
- Massaging the erythematous area (Correct answer)
- Increasing turning frequency
- Keeping the skin clean and dry
Correct answer: Massaging the erythematous area
Massaging over a reddened bony prominence can further damage fragile capillaries and worsen tissue injury.
Question 7: An LPN is assessing a wound with yellow, stringy tissue firmly adherent to the wound bed. This tissue is BEST described as:
- Granulation tissue
- Slough (Correct answer)
- Eschar
- Epithelial tissue
Correct answer: Slough
Slough is yellow, tan, or white soft necrotic tissue that may be stringy or adherent to the wound bed.
LPN Wound Care and Pressure Injury Staging 2
A patient has a pressure injury with full-thickness tissue loss, visible slough covering the wound bed, and undermining present.
Which stage is this?