During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

An area of erythema that is painful to touch.

Shallow open ulcer with a red pink wound bed.

A deep pocket of infection and necrotic tissues.

Visible subcutaneous tissue with sloughing.

Answer and Explanation

The Correct Answer is B

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

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Correct Answer is C

Explanation

A. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.

A. White blood cell count of 8,000/mm3 (8 X 109/L). B. Inelastic skin turgor. C. Serum creatinine of 3.5 mg/dL (310 μmol/L). D. Thin, fragile hand and arm veins.

Correct Answer is C

Explanation

A. A white blood cell count of 8,000/mm³ is within the normal range and does not indicate a need for dosage adjustment.
B. Inelastic skin turgor may indicate dehydration or aging but does not directly affect drug dosage.
C. Elevated serum creatinine levels indicate impaired renal function, which necessitates a reduced dosage of medications excreted through the kidneys, such as ticarcillin disodium.
D. Thin, fragile veins are a concern for intravenous access but do not affect the medication dosage.

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During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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