A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Intact skin with localized erythema.

Full-thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed.

Full-thickness skin loss with visible bone.

Answer and Explanation

The Correct Answer is C

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

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Correct Answer is C

Explanation

A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.

B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.

C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.

D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.

A. Hypoglycemia B. Hypertension C. Hypervolemia D. Hypokalemia

Correct Answer is D

Explanation

A: Hypoglycemia is not a common adverse effect of Furosemide. This diuretic primarily affects fluid and electrolyte balance rather than blood glucose levels.

B: Hypertension is not an adverse effect of Furosemide. In fact, Furosemide is often used to treat hypertension by reducing fluid volume and lowering blood pressure.

C: Hypervolemia, or fluid overload, is not an adverse effect of Furosemide. This medication is a diuretic, which means it helps remove excess fluid from the body, thereby reducing hypervolemia.

D: Hypokalemia, or low potassium levels, is a common adverse effect of Furosemide. This diuretic can cause the body to lose potassium through urine, leading to potentially dangerous low levels of this essential electrolyte.

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A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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