While performing a skin assessment on a bedridden patient, you note a reddish area on the patient's left heel. The skin is intact. The area is nonblanchable. See the picture below.
Based on your findings, you suspect this may be which of the following pressure injury?
Stage I
Stage ii
Stage iii
Stage iv
The Correct Answer is A
A. Stage I pressure injury is characterized by intact skin with a localized area of nonblanchable erythema (redness). The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. The patient in the prompt has intact skin on their heel with a nonblanchable reddish area, which fits this description perfectly.
B. STAGE II: A Stage II pressure injury involves partial-thickness loss of the dermis. It presents as a shallow open ulcer with a red or pink wound bed, without slough or bruising. It may also present as an intact or ruptured serum-filled blister. Since the patient's skin is intact, Stage II is incorrect.
C. STAGE III: A Stage III pressure injury involves full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough and/or eschar may be present. This is a much more severe injury than what is described.
D. STAGE IV: A Stage IV pressure injury involves full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. This is the most severe stage and is clearly not what is pictured or described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Opening of pulmonary and aortic valves: Valve opening is not what produces the heart sounds heard with a stethoscope; heart sounds relate to valve closure.
B. Opening of tricuspid and mitral valves: The sounds detected on auscultation are associated with valve closure events rather than openings.
C. Closure of tricuspid and mitral valves: S1 is produced by the closure of the atrioventricular valves (mitral and tricuspid) at the start of ventricular systole.
D. Closure of pulmonary and aortic valves: Closure of the semilunar valves (aortic and pulmonic) produces S2, which occurs at the end of systole.
Correct Answer is D
Explanation
A. Temperature 99.2: A temperature of 99.2°F is a low-grade elevation that can be expected after surgery and is not the immediate priority.
B. Respiratory rate 18: RR of 18 breaths/min is within normal adult range and not an immediate concern.
C. Blood pressure 148/80: A systolic of 148 is mildly elevated and should be monitored, but it is less immediately alarming in the early postop period than signs of hemodynamic instability.
D. Heart rate 110: A heart rate of 110 bpm (tachycardia) shortly after major surgery may indicate pain, hypovolemia, bleeding, or evolving shock and requires prompt assessment and intervention.
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