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 A

Explanation

A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.

B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.

C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.

D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.

A. Administer the medication and monitor the patient frequently. B. Refuse to give the medication and notify the nurse supervisor. C. Give the patient hydromorphone, as it was meant to be written. D. Call the health care provider to clarify the order.

Correct Answer is D

Explanation

A: Administering the medication and monitoring the patient frequently is not appropriate because phenytoin is not indicated for pain management.

B: Refusing to give the medication and notifying the nurse supervisor is a step in the right direction, but the nurse should also seek clarification from the health care provider.

C: Giving the patient hydromorphone without clarification is not appropriate. The nurse must verify the order with the health care provider.

D: Calling the health care provider to clarify the order is the correct action. This ensures that the correct medication is administered as intended.

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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

A nurse caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What should the nurse do?

Correct Answer is D

Explanation

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