A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Full thickness skin loss with visible bone

Full thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed

Intact skin with localized erythema

Answer and Explanation

The Correct Answer is D

A. Full thickness skin loss with visible bone describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in the wound bed describes a stage 2 pressure injury.
D. Intact skin with localized erythema (redness) that does not blanch when pressure is applied is characteristic of a stage 1 pressure injury.

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Correct Answer is A

Explanation

A. This response emphasizes the importance of the patient controlling their own pain management. PCA pumps are designed to allow the patient to self-administer pain medication as needed, ensuring they receive the appropriate dose based on their pain levels.
B. This response is inappropriate because it undermines the purpose of a PCA pump, which is to allow the patient to control their own pain relief.
C. While the partner's intention is to help, this response does not address the potential risk of over-sedation and respiratory depression when someone other than the patient administers the medication.
D. This response questions the partner's actions but does not provide clear guidance on the proper use of the PCA pump.

A. Apply petroleum jelly to the client's lips after oral care. B. Use the thumb and index finger to keep the client's mouth open. C. Use a stiff toothbrush to clean the client's teeth. D. Turn the client on his side before starting oral care.

Correct Answer is D

Explanation

A. Petroleum jelly can be applied, but it is not the priority action.
B. Using the thumb and index finger to keep the client's mouth open can be unsafe and uncomfortable.
C. A soft toothbrush should be used to prevent injury to the oral mucosa.
D. Turning the client on his side reduces the risk of aspiration during oral care.

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A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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