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 A
Explanation
Choice A rationale:
The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.
Choice B rationale:
The irrigant should be at room temperature, not chilled.
Choice C rationale:
The syringe should be held 1 inch (not 0.5 inch) from the wound.
Choice D rationale:
The wound should be flushed from the cleanest area to the most contaminated, not the other way around.
Correct Answer is B
Explanation
Choice A rationale:
An alert and responsive client who eats 25% of each meal may have nutritional deficiencies, but is able to change position to relieve pressure.
Choice B rationale:
A client who is unresponsive to verbal commands and only changes position occasionally is at high risk for pressure injury due to prolonged pressure on certain areas of the body.
Choice C rationale:
A client who makes frequent slight changes in position and walks occasionally is not at high risk for pressure injury.
Choice D rationale:
A client receiving enteral feeding and can change position independently is not at high risk for pressure injury.
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