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:
Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice B rationale:
Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.
Choice C rationale:
Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Choice D rationale:
Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.
Correct Answer is A
Explanation
Choice A rationale:
The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.
Choice B rationale:
An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.
Choice C rationale:
An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.
Choice D rationale:
A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.
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