A nurse is caring for a patient who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied.
Which of the following statements by the nurse is appropriate?

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

Choice A rationale
Tachycardia is not a common adverse effect of oxygen therapy. It is more likely to be associated with conditions such as fever, anemia, or hypoxia.
Choice B rationale
Poor skin turgor is a sign of dehydration, not a typical adverse effect of oxygen therapy. Oxygen therapy does not directly affect the body’s hydration status.
Choice C rationale
Excessive pulmonary secretions are not a direct adverse effect of oxygen therapy. Conditions such as pneumonia or bronchitis often cause increased secretions.

Choice D rationale
Cracks in the oral mucous membranes can occur as a result of oxygen therapy. Oxygen can dry out the mucous membranes, leading to discomfort and potential cracking.