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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A: Completing proper documentation of the medication error is important but should not be the first action. Immediate assessment of the patient is more critical.

B: Returning to the room to check and assess the patient is the first priority. The nurse needs to determine if the patient has experienced any adverse effects from the medication error and provide appropriate care.

C: Administering the antidote to the patient immediately is only necessary if the medication given has a known antidote and the patient is showing signs of adverse effects. Assessment should come first.

D: Alerting the charge nurse that a medication error has occurred is important for reporting and follow-up but should follow the immediate assessment and care of the patient.

A. The client is attempting to remove the restraint. B. The client’s hand is cold and pale. C. The client has full range of motion in her wrist. D. The client has a capillary refill of less than 2 seconds.

Correct Answer is B

Explanation

A: The client attempting to remove the restraint does not necessarily indicate a need to loosen it. The nurse should assess the reason for the client’s behavior.

B: The client’s hand being cold and pale indicates compromised circulation, which requires immediate loosening of the restraint to restore blood flow.

C: Full range of motion in the wrist suggests that the restraint is not too tight and does not need to be loosened.

D: A capillary refill of less than 2 seconds indicates good circulation, so the restraint does not need to be loosened.

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A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

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