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: Chewing sublingual medication is incorrect. Sublingual medications are designed to dissolve under the tongue for rapid absorption into the bloodstream.
B: Letting the medication dissolve completely is correct. This ensures that the medication is absorbed properly and works effectively.
C: There is no restriction on drinking juice with sublingual medication unless specified by the healthcare provider. This statement does not indicate a clear understanding of sublingual administration.
D: Placing the medication between the cheek and gum is incorrect for sublingual medications. This method is used for buccal medications, not sublingual ones.
Correct Answer is D
Explanation
A: Placing the head of the client’s bed in the flat position is not the appropriate first action. While it may help reduce strain on the abdominal area, it does not address the immediate issue of the exposed bowel.
B: Gently reinserting the bowel back into the client’s wound is not recommended. This action could cause further injury or introduce infection. The nurse should avoid manipulating the exposed bowel.
C: Positioning the client on his left side does not directly address the issue of the exposed bowel. While it may help with comfort, it does not provide the necessary protection for the exposed tissue.
D: Applying moistened sterile gauze to the site is the correct action. This helps protect the exposed bowel from contamination and keeps it moist, which is crucial to prevent tissue damage. The nurse should then notify the surgeon immediately for further instructions.
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