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 B
Explanation
Choice A rationale:
Abdominal pads are not designed to minimize pain during dressing changes.
Choice B rationale:
Hydrogel dressings are known to minimize pain during dressing changes.
Choice C rationale:
Wet-to-dry dressings can cause discomfort during dressing changes.
Choice D rationale:
Dry gauze can stick to the wound bed and cause pain during dressing changes.
Correct Answer is ["A","B","D","E"]
Explanation
E. Using a thermometer to check the temperature of the pad, Securing the pad to the patient, Instructing the patient not to sleep on the pad, Inspecting the plug and cord for cracks or fraying.
Choice A rationale:
It’s important to check the temperature of the pad to prevent burns.
Choice B rationale:
Securing the pad ensures it stays in place and provides consistent heat.
Choice C rationale:
Patients should not lie on top of the pad as it can lead to burns.
Choice D rationale:
Patients should not sleep on the pad to prevent prolonged exposure which can lead to burns.
Choice E rationale:
Inspecting the plug and cord prevents electrical hazards.
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