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 C

Explanation

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

A. “It is never permissible to use herbal supplements with prescription medications." B. "Herbs are not classified as drugs in the United States, so there is no contraindication to using them." C. “I will refer you to an herbalist who can help you decide which medications you can take." D. "Herbs have pharmacologic effects on the body and can interact with some prescription medications."

Correct Answer is D

Explanation

A. It is not accurate to say it is never permissible; some herbal supplements may be safely used with certain medications under professional guidance.
B. Herbs can have pharmacologic effects and may interact with prescription medications, even if they are not classified as drugs in the U.S.
C. Referring to an herbalist is not the best immediate response; the nurse should first address potential interactions and safety concerns.
D. Herbs can indeed have pharmacologic effects and interact with prescription medications, potentially causing adverse effects or altering the effectiveness of the medications.

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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

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