A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Full thickness skin loss with visible bone

Full thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed

Intact skin with localized erythema

Answer and Explanation

The Correct Answer is D

A. Full thickness skin loss with visible bone describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in the wound bed describes a stage 2 pressure injury.
D. Intact skin with localized erythema (redness) that does not blanch when pressure is applied is characteristic of a stage 1 pressure injury.

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Correct Answer is C

Explanation

A. Enteral administration involves the gastrointestinal tract, which has a slower absorption rate.
B. Topical administration involves absorption through the skin, which is also slower.
C. Intravenous (IV) administration delivers medication directly into the bloodstream, providing the fastest rate of absorption.
D. Intramuscular (IM) administration is faster than enteral and topical but slower than intravenous.

A. Stage II B. Stage I C. Stage III D. Stage IV

Correct Answer is C

Explanation

A. Stage II pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
B. Stage I pressure ulcers are characterized by intact skin with non-blanchable redness.
C. Stage III pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
D. Stage IV pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle.

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A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

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