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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?

Full thickness skin loss with visible adipose tissue.

Full thickness skin loss with visible bone.

Intact skin with localized erythema.

Partial-thickness skin loss with red tissue in the wound bed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

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

Choice B rationale:

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

Choice C rationale:

Stage 1 pressure injuries are characterized by intact skin with localized erythema.

Choice D rationale:

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

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Correct Answer is B

Explanation

Choice A rationale:

Refraining from touching the drainage spout with the hand is a correct practice. This helps to prevent contamination of the drain.

Choice B rationale:

Using one alcohol wipe to clean both the spout and the plug is incorrect. Each part should be cleaned with a separate alcohol wipe to prevent cross-contamination.

Choice C rationale:

Pointing the device away from oneself while opening it is a correct practice. This helps to prevent accidental exposure to the drainage fluid.

Choice D rationale:

Compressing the device in the hand before closing is a correct practice. This helps to maintain the suction in the drain.

A. stage 3. B. stage 2. C. stage 4. D. stage 1.

Correct Answer is C

Explanation

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

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A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?