Which next step will the nurse anticipate for a pressure ulcer that is black?

Correct Answer: C

Rationale: Black tissue is necrotic, requiring debridement (Choice C), per the text, to remove infection sources and promote healing. Monitoring delays care. Documentation follows action. Drainage isn't primary. Debridement clears the wound bed, making this the correct anticipated step.

Correct Answer: B

Rationale: Repositioning reduces shear and friction. Using a transfer device to lift (Choice B), per the text, prevents dragging, which damages skin layers in immobile patients. A 30-degree supine position misaligns with the recommended 30-degree lateral tilt to offload pressure points. Elevating the bed 45 degrees increases shear risk, not reduces it. Sliding causes friction, worsening skin stress. Lifting with devices like slide sheets or hoists is evidence-based, minimizing trauma and ensuring safe pressure relief every 2 hours, making this the correct method for nurses to implement.

Correct Answer: D

Rationale: The Braden Scale (6-23) predicts pressure ulcer risk; higher scores indicate lower risk. A score of 23 (Choice D), per the text, is perfect, showing no deficits in sensory perception, moisture, activity, mobility, nutrition, or friction/shear eliminating breakdown risk. Scores of 12 and 13 signal high risk. A score of 20 is good but not optimal. From 15 (moderate risk), achieving 23 confirms all interventions succeeded, making this the correct sign for nurses to aim for.

Correct Answer: B

Rationale: Stage 3 ulcers take time to heal; showing signs of healing in 2 weeks is realistic.

Correct Answer: C

Rationale: Penrose drains are open, unsutured, and not connected to suction, requiring care to avoid dislodgement.