A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Slough tissue is present.

Adipose tissue is present.

Fascia tissue is present.

Undermining is present.

Answer and Explanation

The Correct Answer is C

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

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Correct Answer is D

Explanation

A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.

B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.

C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.

D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.

A. Palpate for pedal pulses. B. Turn the patient every three hours. C. Document the stage 1 pressure injury. D. Elevate bilateral heels.

Correct Answer is A

Explanation

A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.

B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.

C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.

D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

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Naxlex Comprehensive Predictor Exams

After hourly rounds, the primary nurse notes that the patient is agitated, continually pulling at their wound dressings and intravenous lines and has decided to notify the charge nurse. During SBAR, what intervention should the primary nurse recommend?

Correct Answer is D

Explanation

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

Correct Answer is A

Explanation

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