You are assessing a client admitted from a long-term care facility. When noting a stage II pressure injury on the client's coccyx, which of the following would you expect?
An area of non-blanchable redness on intact skin..
An area of shallow broken skin with blistering
Deep purple discoloration over intact skin
An open wound with visible adipose tissue and eschar.
The Correct Answer is B
A. An area of non-blanchable redness on intact skin is characteristic of a stage I pressure injury, not stage II. In stage I, the skin remains intact but shows redness that does not blanch when pressed.
B. An area of shallow broken skin with blistering describes a stage II pressure injury. Stage II involves partial-thickness loss of skin, which may present as a blister or shallow open ulcer, often with a pink or red wound bed.
C. Deep purple discoloration over intact skin refers to a suspected deep tissue injury, which is a different classification of pressure injury. It indicates damage to underlying tissue but does not involve a break in the skin.
D. An open wound with visible adipose tissue and eschar is indicative of a stage III pressure injury, which involves full-thickness skin loss and may expose underlying structures like fat, but not bone or muscle (which would indicate stage IV). Stage III wounds may also have eschar or slough, but stage II wounds do not.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.
Correct Answer is B
Explanation
A. Decreased urine output is not directly associated with elevated potassium levels. It is more commonly linked to renal failure or dehydration.
B. Hyperkalemia (high potassium levels) can lead to ascending muscle paralysis due to its effects on the neuromuscular system. Potassium is critical for proper muscle function, and elevated levels can disrupt the electrical impulses needed for muscle contraction, potentially causing paralysis.
C. Hypoglycemia is unrelated to elevated potassium levels. It is more often associated with insulin use, inadequate food intake, or certain medical conditions.
D. Ascites is fluid accumulation in the abdomen, usually caused by liver disease or heart failure, and is not a direct complication of hyperkalemia.
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