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
Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.
Choice B rationale
Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.
Choice C rationale
While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.
Choice D rationale
Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.
Correct Answer is D
Explanation
Choice A rationale
Providing a list of the client’s current medications during the change of shift report is not a part of medication reconciliation. While it is important to communicate about a patient’s medications during shift changes, medication reconciliation is a more comprehensive process that involves comparing the medications a patient is taking with newly ordered medications.
Choice B rationale
Over-the-counter medications should be included in the medication reconciliation report. Over-the-counter medications can interact with prescription medications and affect a patient’s health, so it’s important to include them in medication reconciliation.
Choice C rationale
Medication reconciliation should be performed for a client at discharge from a health care facility. This is a critical step in ensuring the patient continues to take the correct medications at home.
Choice D rationale
Providing a list of the client’s current medications during admission to a health care facility is a part of medication reconciliation. This helps to ensure that the patient’s medications are correctly managed during their stay in the facility.
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