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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. While a high-calorie, high-protein diet is beneficial for wound healing, it is not the most critical factor in preventing further tissue damage.
B. Changing the patient's position every 2 hours is crucial to relieve pressure on the ulcer and prevent further tissue damage.
C. Changing the patient's linen daily is important for hygiene but does not directly prevent pressure ulcer progression.
D. Recording the size and appearance of the ulcer is important for monitoring, but preventing further damage through repositioning is more critical.

A. Stiffness in the lower extremities B. Difficulty moving the upper extremities C. A reddened area over the sacrum D. Difficulty hearing some types of sounds

Correct Answer is C

Explanation

A. Stiffness in the lower extremities can occur but is not a primary complication of immobility.
B. Difficulty moving the upper extremities is a result of the stroke, not immobility.
C. A reddened area over the sacrum indicates a pressure ulcer, a common complication of immobility.
D. Difficulty hearing some types of sounds is unrelated to immobility.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

Correct Answer is B

Explanation

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

Correct Answer is C

Explanation

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

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

What technique will the nurse implement to assist the postoperative patient to cough?

A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?