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: Auscultation, or listening for air injected into the tube, is not a reliable method for verifying feeding tube placement. It can lead to false positives and does not confirm the tube’s location accurately.

B: X-ray is the gold standard for verifying feeding tube placement. It provides a clear image of the tube’s position, ensuring it is correctly placed in the stomach or small intestine, reducing the risk of complications.

C: Aspiration of contents can help verify placement by checking the appearance and pH of the aspirate. However, it is not as definitive as an X-ray and can sometimes be inconclusive.

D: pH testing of aspirate can indicate whether the tube is in the stomach (acidic pH) or intestines (less acidic). While useful, it is not as reliable as an X-ray for confirming placement.

A. Post a “No Smoking” sign in the home. B. Attach oxygen containers to a fixed object. C. Store spare oxygen tanks in a closet. D. Notify the fire department that oxygen is used in the home. E. Ensure oxygen tubing is no longer than 60 feet in length.

Correct Answer is A

Explanation

A: Posting a “No Smoking” sign in the home is crucial for safety when using home oxygen. Oxygen can accelerate combustion, making even a small spark potentially dangerous. This sign serves as a constant reminder to avoid smoking and open flames near the oxygen source.

B: Attaching oxygen containers to a fixed object is important to prevent them from falling over and potentially causing damage or leaks. However, this is not the most critical instruction compared to ensuring no smoking around oxygen.

C: Storing spare oxygen tanks in a closet is not recommended. Oxygen tanks should be stored in a well-ventilated area to prevent the buildup of oxygen, which could increase the risk of fire.

D: Notifying the fire department that oxygen is used in the home is a good safety measure. It ensures that emergency responders are aware of the presence of oxygen, which can affect their approach in case of a fire. However, it is not as immediate a safety measure as posting a “No Smoking” sign.

E: Ensuring oxygen tubing is no longer than 60 feet in length is important to maintain adequate oxygen flow and prevent tripping hazards. However, this is a secondary safety measure compared to preventing smoking around oxygen.

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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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