A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.

Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.