A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?
Full thickness skin loss with visible adipose tissue.
Full thickness skin loss with visible bone.
Intact skin with localized erythema.
Partial-thickness skin loss with red tissue in the wound bed.
The Correct Answer is C
Choice A rationale:
Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.
Choice B rationale:
Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.
Choice C rationale:
Stage 1 pressure injuries are characterized by intact skin with localized erythema.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.
Choice B rationale:
Double bagging the dressing, labeling it “biohazard,” and sending it for decontamination is incorrect because it is not the standard procedure for disposing of soiled dressings.
Choice C rationale:
Placing the dressing in a biohazardous waste container is the correct method for disposing of soiled dressings.
Choice D rationale:
Discarding the dressing in the bedside trash receptacle is incorrect because it does not follow proper biohazardous waste disposal protocols.
Correct Answer is A
Explanation
Choice A rationale:
The side-lying position allows gravity to assist in wound irrigation and prevent pooling of the solution.
Choice B rationale:
High-Fowler’s position is not ideal for abdominal wound irrigation as it can lead to pooling of the solution.
Choice C rationale:
In the supine position, the solution can pool around the wound and not effectively irrigate it.
Choice D rationale:
The dorsal recumbent position is not ideal as it can also lead to pooling of the solution.
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