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.

Answer and Explanation

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.

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Correct Answer is ["5.6"]

Explanation

Step 1: Convert the toddler’s weight from pounds to kilograms. 1 kg is approximately 2.2 lb. So, 33 lb ÷ 2.2 = 15 kg.

Step 2: Calculate the total daily dose of amoxicillin. The prescribed dose is 30 mg/kg/day. So, 30 mg/kg/day × 15 kg = 450 mg/day.

Step 3: Since the dose is divided into 2 equal doses every 12 hours, each dose will be half of the total daily dose. So, 450 mg/day ÷ 2 = 225 mg/dose.

Step 4: Calculate the volume of the suspension to administer per dose. The available suspension is 200 mg/5 mL. So, (225 mg/dose ÷ 200 mg) × 5 mL = 5.625 mL/dose. Therefore, the nurse should administer approximately 5.6 mL of the amoxicillin suspension per dose.

A. Constipation B. Diarrhea C. Electrolyte imbalance D. Delayed gastric emptying

Correct Answer is B

Explanation

Choice A rationale

Constipation is not typically resolved by diluting enteral feeding formula.

Choice B rationale

Diarrhea can be a common side effect of enteral feeding, and diluting the formula can help manage this.

Choice C rationale

While electrolyte imbalance can occur with enteral feeding, diluting the formula is not typically done to resolve this issue.

Choice D rationale

Delayed gastric emptying is not typically resolved by diluting enteral feeding formula.

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A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 30 mg/kg/day in 2 equally divided doses every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer per dose?

Correct Answer is ["5.6"]

Explanation

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?

Correct Answer is B

Explanation

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