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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Cleaning from left to right across the wound can introduce bacteria from the surrounding skin into the wound, which can lead to infection.

Choice B rationale:

Cleaning from the outer abdomen toward the wound can also introduce bacteria from the surrounding skin into the wound.

Choice C rationale:

Cleaning in a circular motion around the wound, circling to the outside, helps to move bacteria away from the wound and reduce the risk of infection.

Choice D rationale:

Cleaning directly over the wound can disrupt the healing process and potentially introduce bacteria into the wound.

A. tertiary intention. B. remodeling phase. C. primary intention. D. secondary intention.

Correct Answer is A

Explanation

Choice A rationale:

Tertiary intention, also known as delayed primary closure or secondary suture, is a type of wound healing where the wound is initially left open and closed after several days.

Choice B rationale:

The remodeling phase is not a type of wound healing, but a stage of wound healing where the wound fully closes and the new tissue slowly gains strength and flexibility.

Choice C rationale:

Primary intention is a type of wound healing where the wound edges are approximated (brought together) and the wound heals by the process of epithelialization.

Choice D rationale:

Secondary intention is a type of wound healing where the wound is left open and heals by granulation, contraction, and epithelialization.

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A nurse is collecting data on a client who has a stage 1 pressure injury.Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Explanation

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A nurse is collecting data on a client who has a stage 1 pressure injury.
Which of the following findings should the nurse expect?