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 A

Explanation

A: Having another nurse witness the wasted medication is the correct procedure. This ensures accountability and compliance with regulations regarding the handling and disposal of controlled substances.

B: Returning the wasted medication to the medication dispenser is not appropriate. Once a narcotic has been withdrawn, it cannot be returned to the dispenser due to contamination and safety protocols.

C: Placing the wasted portion of the medication in the sharps container is not correct. Narcotics should be disposed of according to specific protocols, which typically involve witnessing and documentation, not simply placing them in a sharps container.

D: Exiting the medication room to call the health care provider to request an order that matches the dosages is unnecessary. The nurse should follow the proper procedure for wasting the medication with a witness.

A. Secure the restraints to the lowest bar of the side rail. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints using a quick-release tie. D. Anticipate removing the restraints every 4 hours.

Correct Answer is C

Explanation

A: Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to prevent injury.

B: Ensuring four fingers fit under the restraints is too loose. The correct fit is typically two fingers to ensure the restraint is secure but not too tight.

C: Securing the restraints using a quick-release tie is correct. This allows for quick removal in case of an emergency.

D: Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked and potentially removed more frequently, typically every 2 hours, to assess skin integrity and circulation.

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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

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Correct Answer is C

Explanation

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