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 A

Explanation

A. Covering the bowel with a sterile saline dressing helps keep the bowel moist and prevents infection.
B. Raising the patient to a high Fowler's position can increase abdominal pressure and worsen the evisceration.
C. Calling the RN is important, but the immediate priority is to protect the protruding bowel.
D. Turning the patient to the side is not appropriate and does not address the immediate need to protect the bowel.

A. Lean patient against the bedside table. B. Splint the abdomen with a pillow. C. Support the patient's back. D. Offer an antitussive.

Correct Answer is B

Explanation

A. Leaning against a bedside table does not provide adequate support or comfort for coughing.
B. Splinting the abdomen with a pillow supports the incision site and reduces pain, making it easier for the patient to cough effectively.
C. Supporting the patient's back is helpful but not as effective as abdominal splinting for reducing pain during coughing.
D. Offering an antitussive is not appropriate as it suppresses coughing, which is needed to clear secretions postoperatively.

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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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