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. 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.

A. Assistance with endotracheal intubation B. Administration of protamine sulfate C. Administration of naloxone (Narcan) D. Administration of oxygen

Correct Answer is C

Explanation

A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.

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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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Naxlex Comprehensive Predictor Exams

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