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: Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to prevent injury.

B: Ensuring four fingers fit under the restraints is too loose. The correct fit is typically two fingers to ensure the restraint is secure but not too tight.

C: Securing the restraints using a quick-release tie is correct. This allows for quick removal in case of an emergency.

D: Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked and potentially removed more frequently, typically every 2 hours, to assess skin integrity and circulation.

A. Check the dosage with a more experienced nurse. B. Consult a drug handbook and administer the normal dose. C. Contact the hospital pharmacist about the order. D. Contact the health care provider to clarify the illegible order.

Correct Answer is D

Explanation

A: Checking the dosage with a more experienced nurse is not the best action. While it may provide some guidance, it does not ensure the accuracy of the order.

B: Consulting a drug handbook and administering the normal dose is not appropriate. The nurse must verify the specific order for the patient rather than assuming a standard dose.

C: Contacting the hospital pharmacist about the order can be helpful, but the pharmacist may not be able to clarify the prescriber’s intent if the order is illegible.

D: Contacting the health care provider to clarify the illegible order is the best action. This ensures that the nurse administers the correct dose as intended by the prescriber, preventing medication errors.

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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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