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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Auscultation, or listening for air injected into the tube, is not a reliable method for verifying feeding tube placement. It can lead to false positives and does not confirm the tube’s location accurately.
B: X-ray is the gold standard for verifying feeding tube placement. It provides a clear image of the tube’s position, ensuring it is correctly placed in the stomach or small intestine, reducing the risk of complications.
C: Aspiration of contents can help verify placement by checking the appearance and pH of the aspirate. However, it is not as definitive as an X-ray and can sometimes be inconclusive.
D: pH testing of aspirate can indicate whether the tube is in the stomach (acidic pH) or intestines (less acidic). While useful, it is not as reliable as an X-ray for confirming placement.
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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