A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

Stage III pressure injury

Stage IV pressure injury

Stage II pressure injury

Stage I pressure injury

Answer and Explanation

The Correct Answer is D

A. Stage III pressure injury

Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.

B. Stage IV pressure injury

Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.

C. Stage II pressure injury

Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.

D. Stage I pressure injury

Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.

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Correct Answer is B

Explanation

A. Elevated hemoglobin:

Elevated hemoglobin levels are not typically associated with aging or factors that affect pressure injury healing. Hemoglobin levels primarily relate to blood oxygen-carrying capacity and are influenced by factors such as hydration status, kidney function, and certain medical conditions.

B. Decreased protein level:

This is a significant factor that can impact the ability of a pressure injury to heal in older adults. Decreased protein levels, specifically serum albumin and total protein, are common in aging individuals and can contribute to impaired wound healing. Protein is essential for tissue repair, collagen synthesis, and immune function.

C. Low bone density:

While low bone density (osteoporosis) is a concern in aging adults and can increase the risk of fractures, it is not directly related to the ability of a pressure injury to heal. However, bone density can indirectly impact wound healing if fractures or bone-related complications occur.

D. Increased muscle mass:

Increased muscle mass is generally beneficial for overall health and functional abilities in older adults. However, it is not directly related to the ability of a pressure injury to heal.

A. “Call your surgeon if you have any questions at home.” B. ”Eat a diet high in protein, iron, zinc, and vitamin C.” C. “Wash your hands before touching the drain or dressing." D. “Be sure you keep all your postoperative appointments.”

Correct Answer is C

Explanation

A. “Call your surgeon if you have any questions at home.”

This instruction is important as it encourages the patient to seek help and clarification if they have any concerns or questions about their postoperative care at home. However, while communication with the surgeon is essential, it is not as immediately critical as ensuring proper hand hygiene when dealing with wound care and drain management.

B. ”Eat a diet high in protein, iron, zinc, and vitamin C.”

Nutritional advice is crucial for postoperative recovery, as a balanced diet high in protein, iron, zinc, and vitamin C can promote wound healing and overall recovery. However, while important for long-term recovery and healing, dietary recommendations do not directly address the immediate risk of infection or complications associated with wound care and drain management.

C. “Wash your hands before touching the drain or dressing."

This instruction is the most important in this context because proper hand hygiene is crucial for preventing infections during wound care and drain management. Clean hands significantly reduce the risk of introducing harmful bacteria or contaminants to the surgical site, which can lead to infections and other complications. Ensuring that the patient washes their hands before touching the drain or dressing is a fundamental measure for promoting wound healing and preventing postoperative complications.

D. “Be sure you keep all your postoperative appointments.”

Keeping postoperative appointments is important for ongoing assessment, monitoring, and follow-up care. However, while essential for overall recovery and management of postoperative issues, it is not as immediate or directly related to the patient's ability to manage their dressing and drain at home.

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A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?

Nursing Test Bank

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