A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?
stage I
stage II
stage III
stage IV
stage IV
The Correct Answer is D
The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Contact Precautions. Clostridium difficile (C-diff) is a bacterium that can cause severe diarrhea and other gastrointestinal problems. It is highly contagious and spreads through contact with contaminated surfaces or objects. Therefore, it is necessary to apply Contact Precautions for patients with C-diff to prevent the transmission of the infection. Contact Precautions involve wearing gloves and gowns when entering the patient's room and disposing of contaminated items properly. Additionally, hand hygiene is critical to preventing the spread of C-diff.
Correct Answer is B
Explanation
The correct answer is choice B, Use water and mild soap.
When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.
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