A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
Intact skin with localized erythema.
Full thickness skin loss with visible bone
Full thickness skin loss with visible adipose tissue.
Partial-thickness skin loss with red tissue in wound bed.
The Correct Answer is D
A. Intact skin with localized erythema:
Explanation: This description is more consistent with a stage 1 pressure injury, where there is non-blanchable erythema.
B. Full thickness skin loss with visible bone:
Explanation: This description is more consistent with a stage 4 pressure injury, which involves extensive tissue loss, including exposure of bone.
C. Full thickness skin loss with visible adipose tissue:
Explanation: This finding is characteristic of a stage 3 pressure injury, where the loss of tissue extends down to the subcutaneous layer.
D. Partial-thickness skin loss with red tissue in the wound bed:
Explanation: This description is consistent with a stage 2 pressure injury, where there is partial-thickness skin loss involving the epidermis and possibly the dermis, forming a shallow open ulcer with a red-pink wound bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Iron:
Function: Iron is essential for the formation of hemoglobin, a protein in red blood cells that carries oxygen from the lungs to the rest of the body. It is vital for oxygen transport and overall cellular function.
Relevance: Iron deficiency can lead to anemia, characterized by reduced oxygen-carrying capacity of the blood, resulting in fatigue, weakness, and other symptoms.
B. Magnesium:
Function: Magnesium is involved in various cellular processes, including muscle and nerve function, blood glucose control, and bone health.
Relevance: While magnesium has important functions in the body, it is not directly involved in the transport of oxygen like iron.
C. Phosphorus:
Function: Phosphorus is a key component of DNA, RNA, and ATP, playing a role in energy metabolism, bone health, and acid-base balance.
Relevance: While important for cellular processes, phosphorus is not specifically linked to the transport of oxygen.
D. Potassium:
Function: Potassium is crucial for maintaining proper fluid balance, nerve impulses, and muscle contractions.
Relevance: Potassium is not directly involved in the transport of oxygen; its primary functions are related to electrolyte balance and cellular activities.
Correct Answer is C
Explanation
A. Cimetidine:Cimetidine can indeed increase the effect of metformin due to competition for renal tubular clearance. This can lead to higher levels of metformin in the blood and potentially increase the risk of side effects. While it does not directly contraindicate metformin use, monitoring and dose adjustments might be necessary to manage this interaction.
B. Cephalexin:
Cephalexin is an antibiotic used to treat bacterial infections. It does not have a significant impact on blood glucose levels and is not contraindicated for a client taking metformin.
C. Prednisone:This is a corticosteroid that can increase blood glucose levels. Corticosteroids are known to cause hyperglycemia and may impair glucose control, which can be problematic for someone with diabetes taking metformin.
D. Levothyroxine:
Levothyroxine is a medication used to treat hypothyroidism. It does not have a direct impact on blood glucose levels and is not contraindicated for a client taking metformin.
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