A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Slough tissue is present.

Adipose tissue is present.

Fascia tissue is present.

Undermining is present.

Answer and Explanation

The Correct Answer is C

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

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Correct Answer is B

Explanation

A. Obtain daily urine specimens by opening the collection drainage system: Opening the drainage system increases the risk of introducing bacteria into the catheter, which can lead to infection.

B. Keep the urine collection bag below the level of the bladder at all times: Keeping the bag below the bladder prevents urine from back flowing into the bladder, which reduces the risk of infection.

C. Retract the foreskin to clean the catheter tubing and meatus outward, leaving the foreskin retracted: While the foreskin should be retracted for cleaning, it must always be returned to its normal position to prevent paraphimosis, a condition where the foreskin becomes trapped and restricts blood flow.

D. Change the indwelling catheter at least every one week: Routine catheter changes are not recommended unless there is an indication such as obstruction or infection. Unnecessary changes increase infection risk.

A. Avoid bathing this patient until they are stable. B. Only bathe the perineal area. C. Perform the bath in a semi-Fowler's position. D. Delegate the task to the assistive personnel.

Correct Answer is C

Explanation

A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.

B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.

C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.

D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.

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A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Nursing Test Bank

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