A nurse is attending to a patient who is unable to move.
Which stage of pressure injuries is most likely indicated by the presence of non-blanchable erythema on the patient’s heels?
Stage I pressure injury.
Stage II pressure injury.
Stage III pressure injury.
Stage IV pressure injury.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Cleaning the inside of the container with a wipe is not recommended. The container provided for a urine sample is sterile, and cleaning it could introduce bacteria, contaminating the sample.
Choice B rationale
The statement “I will urinate a little then stop” is correct. This is part of the process of collecting a midstream urine sample. The initial stream of urine can contain bacteria from the urethra or genital area, so it’s recommended to start urinating, then stop and collect the sample midstream.
Choice C rationale
The statement “I will use each cleansing wipe twice” is incorrect. Each cleansing wipe should only be used once to avoid reintroducing bacteria.
Choice D rationale
The statement “I will use the cleansing wipe from front to back” is correct. This is the proper way to clean the genital area to avoid introducing bacteria from the anal area into the urethra.
Correct Answer is B
Explanation
Choice A rationale
Phosphate levels are not directly affected by spironolactone. Spironolactone is a potassium- sparing diuretic and does not typically affect phosphate levels.
Choice B rationale
Decreased potassium level is not typically expected in a patient taking spironolactone. Spironolactone is a potassium-sparing diuretic, meaning it can actually lead to increased potassium levels. However, in the context of liver failure and ascites, other factors may influence potassium levels.
Choice C rationale
Chloride levels are not directly affected by spironolactone. Spironolactone primarily affects the balance of potassium and sodium in the body.
Choice D rationale
Sodium levels could potentially be decreased in a patient taking spironolactone, as it can cause the body to lose sodium. However, in the context of liver failure and ascites, sodium levels are often carefully managed.
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