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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Health care providers such as medical doctors (MDs) and nurse practitioners (NPs) are responsible for diagnosing and treating medical conditions. While they play a crucial role in patient care, the development of a detailed, individualized nursing plan of care typically falls under the domain of nursing professionals.

Choice B reason: Licensed practical/vocational nurses (LPNs/LVNs) provide basic patient care under the supervision of registered nurses and physicians. They assist with implementing care plans but do not usually develop comprehensive nursing plans of care themselves.

Choice C reason: Nursing supervisors oversee the nursing staff and ensure that nursing care is delivered effectively. They may be involved in developing and overseeing care plans at a higher level but are not typically responsible for creating the individualized care plans for each patient.

Choice D reason: Registered nurses (RNs) are trained and licensed to develop individualized care plans that include nursing diagnoses, interventions, and outcomes. They work closely with patients to create and implement care plans that address specific health needs and promote self-management.

A. Administer antibiotics B. Start IV fluids C. Assess pain every 4 hours D. Maintain oxygenation

Correct Answer is D

Explanation

Choice A reason: Administering antibiotics is essential for treating cellulitis to eliminate the infection. However, it is not the immediate priority over maintaining oxygenation, especially in a patient with sickle cell disease.

Choice B reason: Starting IV fluids is crucial for preventing dehydration and helping to reduce the sickling of red blood cells. Nevertheless, while important, it is not the most urgent action compared to maintaining adequate oxygen levels.

Choice C reason: Assessing pain every 4 hours is necessary for managing the patient's comfort and monitoring the progression of the disease. Although pain management is a significant aspect of care, it is not the top priority in this scenario.

Choice D reason: Maintaining oxygenation is the highest priority for a patient with sickle cell disease. These patients are at increased risk for hypoxia, which can exacerbate the sickling of red blood cells, leading to severe complications such as acute chest syndrome or stroke. Ensuring adequate oxygenation helps to prevent these complications and stabilizes the patient's condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In any clinical setting, which health care team member is responsible for developing an individualized plan of care that includes nursing diagnoses, interventions, and outcomes including the patient's self-management care plan?

Correct Answer is D

Explanation

A patient with sickle cell disease has developed cellulitis above the left ankle. Which action is the nurse's priority for this patient?

Correct Answer is D

Explanation

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