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 D
Explanation
Choice A reason: A hemoglobin level of 12.0 g/dL is slightly below the normal range for men but is not the most critical concern preoperatively. It indicates mild anemia, which should be monitored but does not present an immediate high risk.
Choice B reason: A serum creatinine level of 1.3 mg/dL is slightly elevated and indicates mild renal impairment. While this should be considered, it is not as immediately concerning as a significantly abnormal coagulation value.
Choice C reason: A Blood Urea Nitrogen (BUN) level of 24 mg/dL is slightly above normal, indicating some renal function impairment or dehydration. However, it does not pose the most significant immediate risk compared to a high INR value.
Choice D reason: An INR of 3.5 is significantly elevated and indicates a high risk of bleeding. For a surgical patient, this is the most concerning pre-op lab value because it suggests that the patient's blood is not clotting properly. This increases the risk of excessive bleeding during and after surgery, making it a priority to address before proceeding with the operation.
Correct Answer is B
Explanation
Choice A reason: Kidney failure is not a common immediate complication related to the patient's presentation of sudden right-sided weakness and difficulty speaking, which are indicative of a stroke. Although diabetes and hypertension can eventually lead to kidney issues, this is not an acute complication.
Choice B reason: Aspiration pneumonia is a potential complication of the patient's condition, especially given the presence of expressive aphasia. Patients with neurological deficits, particularly those affecting speech and swallowing, are at higher risk of aspirating food or liquids into the lungs, leading to pneumonia.
Choice C reason: Hypotension is not commonly a direct complication of a stroke, especially considering the patient's elevated blood pressure. Stroke patients often present with hypertension rather than hypotension.
Choice D reason: Heart failure, while related to the patient's underlying conditions like hypertension and possibly diabetes, is not an immediate complication of the acute neurological event described. The focus should be more on the neurological and respiratory complications.
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