Which characteristic distinguishes a stage 2 pressure injury from a stage 3 pressure injury?
Presence of slough or eschar.
Nonblanchable erythema.
Exposed muscle or bone.
Partial-thickness skin loss.
The Correct Answer is D
A. Presence of slough or eschar: Both Stage 2 and Stage 3 injuries may eventually develop some slough if they deteriorate or if they are mismanaged. However, slough and eschar are defining characteristics of an unstageable injury if they obscure the wound base. A clean Stage 2 injury will not have slough or eschar.
B. Nonblanchable erythema: Nonblanchable erythema is the defining characteristic of a Stage 1 pressure injury, which involves intact skin. Stage 2 and Stage 3 both involve skin loss.
C. Exposed muscle or bone: Exposed muscle or bone indicates a Stage 4 pressure injury.
D. Partial-thickness skin loss: A Stage 2 pressure injury is defined by partial-thickness loss of the dermis. A Stage 3 pressure injury is defined by full-thickness tissue loss involving the subcutaneous fat. This difference in thickness is the key distinction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Irrigate the drain with sterile saline:Drain irrigation should only be performed with a specific provider order because it risks introducing bacteria into the sterile surgical site or causing tissue damage. The nurse should first attempt less invasive methods to restore function.
B. Notify the healthcare provider immediately:While the provider must be notified of a non-functioning drain and concerning symptoms, the nurse's first action is to assess and attempt to correct the issue to re-establish drainage.
C. Increase the patient's oral fluid intake:Increasing oral fluid intake will not correct a mechanical issue like a clogged or misplaced drain.
D. Reposition the drain:The Jackson-Pratt (JP) drain works via continuous negative pressure (suction). If the reservoir is full, if the tubing is kinked, or if the drain tip is lodged against tissue, drainage will stop. The nurse's first action should be to assess the suction (empty and re-compress the bulb/reservoir) and gently reposition the drain tubing to ensure it's straight, non-kinked, and lying correctly. If this does not restore drainage, the provider should be notified immediately.
Correct Answer is C
Explanation
A. Presence of a blister on the skin: A blister, usually indicating separation of the epidermis and dermis, is characteristic of a Stage 2 pressure injury or a Deep Tissue Pressure Injury (DTPI).
B. Exposed bone or muscle: Exposed bone or muscle signifies a Stage 4 pressure injury, which is full-thickness skin and tissue loss.
C. A localized area of skin that is warm to the touch: In darker skin tones, a Stage 1 pressure injury (which is intact skin) is often identified by changes in skin temperature (localized warmth or coolness) or consistency (edema, firmness, or boggy feel), rather than visible reddening. The area may appear darker, taut, or purplish, and the warmth is due to the underlying inflammatory response.
D. Presence of a deep crater in the skin: A deep crater suggests a significant loss of tissue depth, characteristic of a Stage 3 or 4 pressure injury.
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