A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula.

The nurse recognizes this is being done to resolve which of the following conditions?

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice A rationale

The stoma for a sigmoid colostomy is typically located in the lower left abdomen. This is because the sigmoid colon is a part of the large intestine that is located in the lower left quadrant of the abdomen.

Choice B rationale

A stoma should appear pink or red and moist. A purple stoma could indicate a lack of blood supply, which is a medical emergency.

Choice C rationale

A sigmoid colostomy will produce formed stool because the sigmoid colon is the last part of the colon, where water is absorbed and stool is formed.

Choice D rationale

The end of the stoma (the part that sticks out from the abdomen) should not be painful after the procedure. If a patient experiences pain, it could indicate a complication such as a blockage or infection.