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 B

Explanation

A: Continuous output from the stoma is expected in patients with an ileostomy. The stoma continuously produces waste, and this is a normal finding.

B: The presence of blood in the stool is an abnormal finding and should be reported immediately. It could indicate bleeding within the gastrointestinal tract, which requires prompt medical evaluation and intervention.

C: Malodorous stool is common with an ileostomy and is not typically a cause for immediate concern. However, if the odor is unusually strong or different, it may warrant further investigation.

D: Liquid consistency of stool is normal for an ileostomy, as the large intestine, which absorbs water, is bypassed. This is not an immediate concern unless there are other symptoms present.

A. Consult a dietitian. B. Apply a hydrogel dressing. C. Clean the wound with hydrogen peroxide. D. Use a low-air-loss therapy unit.

Correct Answer is C

Explanation

The correct answer is C.

A: Consulting a dietitian is a beneficial order for a patient with a pressure ulcer. Proper nutrition, especially adequate protein intake, is crucial for wound healing. A dietitian can help ensure the patient receives the necessary nutrients to support tissue repair and recovery.

B: Applying a hydrogel dressing is appropriate for a clean, granulating Stage II pressure ulcer. Hydrogel dressings maintain a moist wound environment, which promotes healing and provides pain relief. They are suitable for wounds with minimal to moderate exudate.

C: Cleaning the wound with hydrogen peroxide is not recommended for a healing pressure ulcer. Hydrogen peroxide can damage healthy granulating tissue and delay the healing process. It is better to use saline or a wound cleanser that does not harm the new tissue.

D: Using a low-air-loss therapy unit is beneficial for patients with pressure ulcers. These units help reduce pressure on the skin, improve circulation, and prevent further skin breakdown. They are an effective part of pressure ulcer management.

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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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