A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?
Stage 2
Stage 1
Stage 3
Stage 4
The Correct Answer is C
Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.
Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.
Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.
Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering Furosemide (Lasix) 40 mg IV is important for reducing fluid overload, but the immediate priority is to address the patient's low oxygen saturation levels.
Choice B reason: Assessing lung sounds and peripheral edema is important for ongoing monitoring, but the immediate action should focus on stabilizing the patient's oxygen levels.
Choice C reason: Placing the patient on oxygen to titrate to oxygen saturations 94% or greater is the most immediate and critical intervention. The patient's oxygen saturation is significantly low at 86%, and addressing this ensures adequate oxygenation and reduces the risk of hypoxia.
Choice D reason: Educating the patient on lifestyle modifications is important for long-term management but is not the immediate priority in an acute situation.
Correct Answer is A
Explanation
Choice A reason: A blood pressure of 128/76 mm Hg is within the target range for a patient with hypertension, indicating that the current therapy is effectively managing the condition. This reading is below the generally accepted threshold for hypertension, which is 140/90 mm Hg.
Choice B reason: A blood pressure of 148/78 mm Hg is above the target range for hypertension management. This reading suggests that the patient may need an adjustment in their therapy to better control their blood pressure and reduce the risk of cardiovascular complications.
Choice C reason: A blood pressure of 98/56 mm Hg is too low and may indicate hypotension, which can be a concern, especially if the patient experiences symptoms like dizziness or fainting. This reading suggests that the patient's therapy may need to be adjusted to avoid excessively lowering blood pressure.
Choice D reason: A blood pressure of 128/92 mm Hg shows an elevated diastolic pressure, which is above the target range. This indicates that the patient's hypertension is not fully controlled, and adjustments in therapy may be needed to bring both systolic and diastolic pressures within the desired range.
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