A nurse has delegated the application of wrist restraints to an assistive personnel (AP) for a confused patient. The AP has padded the wrist restraints and secured the straps to the bed frame with a double knot.
What action should the nurse take?

Choice A rationale

Full-thickness tissue loss extending to underlying support structures such as muscle, tendon, or bone is characteristic of a stage 4 pressure ulcer, not a stage 312.
Choice B rationale
A stage 3 pressure ulcer involves full-thickness skin loss and may appear as a deep crater. There may be damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This description matches the statement in Choice B, making it the correct answer.
Choice C rationale
A shallow, ruptured or intact skin blister without slough is more indicative of a stage 2 pressure ulcer. In a stage 2 pressure ulcer, there is partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
Choice D rationale
Unbroken skin with un-blancheable erythema is characteristic of a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin is not broken, but it has redness that does not lighten (or blanch) when you press on it.

Choice A rationale
The nurse should wait for 30 minutes and then measure the client’s oral temperature. Consuming cold substances like ice chips can temporarily lower the oral temperature, leading to inaccurate readings. Therefore, it’s recommended to wait for a period of time to allow the oral temperature to return to its normal state.
Choice B rationale
Proceeding to measure the client’s oral temperature immediately after consuming ice chips would likely result in an inaccurately low reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Documenting the inability to obtain an accurate reading of the client’s oral temperature is not the best action in this situation. While it’s important to document any factors that might affect the accuracy of a temperature reading, in this case, the nurse can simply wait a period of time after the client has consumed the ice chips before taking the oral temperature.
Choice D rationale
Providing the client a sip of warm water and waiting 5 minutes before measuring his oral temperature may not be sufficient to ensure an accurate temperature reading. The mouth needs adequate time to return to its normal temperature after consuming something cold.