A nurse is assisting a healthcare provider with a sterile procedure and is preparing to pour solution onto a sterile piece of gauze.
In what sequence should the nurse perform the following steps when pouring the sterile solution?

Choice A rationale

Stage I pressure injury is characterized by non-blanchable erythema of intact skin. This means that the skin does not turn white when pressed and is a sign of damage to the underlying

tissues. This stage is often seen in areas of the body that are under constant pressure, such as the heels in a patient who is unable to move.

Choice B rationale

Stage II pressure injury involves partial-thickness loss of skin with exposed dermis. This stage is more severe than stage I and would present with an open wound, which is not described in the question.

Choice C rationale

Stage III pressure injury involves full-thickness loss of skin, in which fatty tissue is visible in the wound. This stage is more severe than both stages I and II and would present with a deeper wound, which is not described in the question.

Choice D rationale

Stage IV pressure injury involves full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. This is the most severe stage of pressure injury and would present with a very deep wound exposing underlying structures, which is not described in the question.

Choice A rationale

Sensation of pressure is a common symptom of urinary retention due to prostatic hypertrophy.

Choice B rationale

Dysuria, or painful urination, can occur due to the enlarged prostate pressing against the urethra.

Choice C rationale

Bladder distension is a result of the bladder becoming overly full due to inability to fully empty the bladder.

Choice D rationale

Tenderness over the symphysis pubis can occur due to the bladder being overly full and distended.