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 D

Explanation

A. Hepatitis screening typically involves blood tests.
B. Meningitis is diagnosed through lumbar puncture and laboratory tests, not intradermal injection.
C. Diabetes screening involves blood glucose testing, not intradermal injection.
D. Tuberculosis (TB) screening is commonly performed using an intradermal injection, known as the Mantoux tuberculin skin test.

A. Inform the provider that the PCA is not providing adequate pain relief. B. Ask the provider for a prescription to decrease the continuous rate. C. Instruct the client to push the button more frequently. D. Instruct the client's caregiver to push the PCA button when the client is resting.

Correct Answer is C

Explanation

A. The nurse should not inform the provider that the PCA is not providing adequate pain relief, as this is not true based on the client's pain rating of 2 out of 10.
B. The nurse should not ask the provider for a prescription to decrease the continuous rate, as this may compromise the client's pain relief and comfort.
C. The client should be encouraged to use the PCA pump before the pain becomes severe, as this will provide better pain control and reduce the risk of side effects.
D. Instructing the caregiver to push the button without the client's request may lead to overmedication and potential respiratory depression.

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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

What screening test is accomplished by performing an Intradermal injection?

Correct Answer is D

Explanation

A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Which fluid or product to be infused requires a central venous access rather than a peripheral access?

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