A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?
Full-thickness skin loss with visible bone.
Full-thickness skin loss with visible adipose tissue.
Skin remains intact with localized erythema.
Partial-thickness skin loss with red tissue in the wound bed.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale
A specific gravity of 1.036 is higher than the normal range of 1.005 to 1.030345. This could indicate dehydration or other conditions that cause the urine to be more concentrated. This finding should prompt the nurse to follow up.
Choice B rationale
A pH of 6.4 is within the normal range for urine, which is typically between 4.6 and 8.03. Therefore, this finding would not necessarily require follow-up.
Choice C rationale
The presence of proteinuria (protein in the urine) is abnormal and could indicate kidney disease or other serious health conditions. This finding should prompt the nurse to follow up.
Choice D rationale
The presence of hematuria (blood in the urine) can be a sign of several conditions, including urinary tract infections, kidney stones, or bladder infections. However, without more information, it’s not clear whether this finding alone should prompt the nurse to follow up.
Correct Answer is A
Explanation
Choice A rationale
Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.
Choice B rationale
Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.
Choice C rationale
Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.
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