A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
Intact skin with localized erythema.
Full-thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed.
Full-thickness skin loss with visible bone.
The Correct Answer is C
A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.
B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.
C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.
D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.
B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.
C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.
D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.
Correct Answer is ["740"]
Explanation
Step 1: Convert 4 oz juice to mL. 4 oz × 30 mL per oz = 120 mL
Step 2: Convert 6 oz hot tea to mL. 6 oz × 30 mL per oz = 180 mL
Step 3: Ice chips are recorded at half their volume. 100 mL ÷ 2 = 50 mL
Step 4: IV bolus is already in mL. 150 mL
Step 5: Convert 8 oz broth to mL. 8 oz × 30 mL per oz = 240 mL
Step 6: Add all the volumes together. 120 mL + 180 mL + 50 mL + 150 mL + 240 mL = 740 mL
The nurse should record 740 mL of intake on the client’s record.
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