A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula.

The nurse recognizes this is being done to resolve which of the following conditions?

Choice A rationale

Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.

Choice A rationale

Sterile gloves are not necessary when checking a patient’s pulse. They are typically used for procedures that require aseptic technique, such as wound dressing changes or insertion of a central venous catheter.

Choice B rationale

Protective eyewear is used to protect the healthcare provider from splashes or sprays of blood, body fluids, secretions, or excretions. It is not necessary when checking a patient’s pulse.

Choice C rationale

Clean gloves should be worn when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. This includes when caring for a patient with MRSA in an abdominal wound.

Choice D rationale

An N95 respirator mask is used to protect the healthcare provider from airborne pathogens, such as tuberculosis. It is not necessary when checking a patient’s pulse.