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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 B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

A. applying hydrocolloids to the wound bed. B. placing a transparent dressing over the pressure injury. C. pulsating lavage. D. using a topical enzyme solution in the wound bed.

Correct Answer is C

Explanation

Choice A rationale:

Hydrocolloids are not a form of mechanical debridement. They are dressings that promote autolytic debridement by maintaining a moist wound environment.

Choice B rationale:

Transparent dressings are not a form of mechanical debridement. They are used to protect the wound and allow for visual inspection.

Choice C rationale:

Pulsating lavage is a form of mechanical debridement. It involves using a pressurized, pulsed solution to remove necrotic tissue from the wound bed.

Choice D rationale:

Topical enzyme solutions are not a form of mechanical debridement. They are a form of chemical debridement that breaks down necrotic tissue.

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