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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Free Nursing Study Resources

Correct Answer is ["4.0"]

Explanation

Step 1: Determine the dosage required. 320 mg

Step 2: Determine the concentration of the suspension. 400 mg per 5 mL

Step 3: Calculate the volume needed. 320 mg ÷ 400 mg per 5 mL = 320 ÷ 400 × 5 = 0.8 × 5 = 4 mL

The nurse should administer 4.0 mL per dose.

A. Continuous output from the stoma B. Presence of blood in the stool C. Malodorous stool D. Liquid consistency of stool

Correct Answer is B

Explanation

A: Continuous output from the stoma is expected in patients with an ileostomy. The stoma continuously produces waste, and this is a normal finding.

B: The presence of blood in the stool is an abnormal finding and should be reported immediately. It could indicate bleeding within the gastrointestinal tract, which requires prompt medical evaluation and intervention.

C: Malodorous stool is common with an ileostomy and is not typically a cause for immediate concern. However, if the odor is unusually strong or different, it may warrant further investigation.

D: Liquid consistency of stool is normal for an ileostomy, as the large intestine, which absorbs water, is bypassed. This is not an immediate concern unless there are other symptoms present.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 320 mg PO every 12 hours to an infant. The amount available is amoxicillin suspension 400 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4.0"]

Explanation

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?

Correct Answer is B

Explanation

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