Upon assessment of the client, the nurse notes two open wounds to the client's left dorsal foot and medial second toe. Client reports pain with elevation of lower extremities. The nurse notes both wounds without exudate. Based on this assessment criteria, how would the nurse identify this wound in report?

Arterial ulcers

Diabetic foot ulcers

Venous stasis ulcers

Stage two pressure injuries

Answer and Explanation

The Correct Answer is A

A. Arterial ulcers: These wounds typically occur on distal points such as the toes or the dorsal aspect of the foot due to poor tissue perfusion. A hallmark sign is "rest pain" that worsens with elevation, as gravity no longer assists blood flow to the extremities. They often appear dry or "punched out" without significant exudate.

B. Diabetic foot ulcers: While these occur on the feet, they are primarily associated with peripheral neuropathy and occur on pressure-bearing plantigrade surfaces. The pain reported with elevation is more characteristic of macrovascular arterial disease than pure diabetic neuropathy. Neuropathic ulcers are often painless due to the loss of sensory perception.

C. Venous stasis ulcers: These ulcers are usually located near the medial malleolus and are characterized by irregular borders and significant edema. Unlike arterial ulcers, the pain associated with venous disease is typically relieved by elevation, which promotes venous return. They are also highly exudative, which contradicts the "without exudate" assessment.

D. Stage two pressure injuries: These involve partial-thickness loss of the dermis and are caused by sustained mechanical pressure over bony prominences. The dorsal foot and medial toe are less common sites for pressure injuries unless caused by ill-fitting footwear. The specific pain pattern with elevation strongly points toward a vascular rather than a mechanical etiology.

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Correct Answer is B

Explanation

A. Unstageable injury: This classification applies when the true depth of tissue damage is obscured by slough or eschar. The presence of visible, intact skin with erythema allows for a definitive assessment. Because the wound bed is not covered by necrotic debris, this category is clinically inapplicable.

B. Stage 1 pressure injury: This stage is characterized by localized, non-blanchable redness over a bony prominence like the trochanter. The skin remains intact, though the area may be painful or different in temperature. It represents the earliest detectable stage of pressure-induced tissue ischemia and compromise.

C. Stage 2 pressure injury: This injury involves partial-thickness loss of the dermis, appearing as a shallow open ulcer or a serum-filled blister. The question specifies that the skin remains intact, which rules out any epidermal or dermal loss. It lacks the characteristic pink or red moist wound bed.

D. Deep tissue pressure injury (DTI): This manifests as persistent non-blanchable deep red, maroon, or purple discoloration, often feeling mushy or boggy. While it involves intact skin, the specific description of erythema fits a Stage 1 injury better. DTI suggests deeper underlying damage than simple superficial redness.

A. Obtain a set of vital signs B. Stop the antibiotic infusion C. Notify the healthcare provider D. Initiate oxygen via nasal cannula at 2 LPM

Correct Answer is B

Explanation

A. Obtain a set of vital signs: While monitoring hemodynamics is essential during an allergic reaction, it is not the immediate priority while the allergen is still entering the bloodstream. Delaying the cessation of the infusion to gather data allows more of the provocative agent to reach systemic circulation. Vital signs are the second step after stopping the trigger.

B. Stop the antibiotic infusion: The client is exhibiting classic signs of a Type 1 hypersensitivity reaction, which can rapidly progress to life-threatening anaphylaxis. The most critical intervention is to immediately terminate the exposure to the offending pharmacological agent. This limits further mast cell degranulation and the systemic release of histamine and leukotrienes.

C. Notify the healthcare provider: Communication with the provider is necessary to obtain orders for epinephrine or antihistamines, but it must follow the physical intervention of stopping the drug. The nurse must prioritize patient safety by halting the infusion before leaving the bedside or picking up the phone. Immediate action prevents further physiological deterioration.

D. Initiate oxygen via nasal cannula at 2 LPM: Oxygen therapy addresses the symptom of wheezing but does not stop the underlying immunological cascade caused by the piperacillin. While respiratory support may be required, it is a supportive measure that follows the removal of the primary allergen. Stopping the infusion is the only action that halts the cause of the distress.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an immobile client and identifies these findings: Painful, persistent non-blanchable erythema at site of right greater trochanter. Skin remains intact. How would the nurse identify these findings in documentation?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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