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.

Answer and Explanation

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.

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Correct Answer is B, A, C, D

Explanation

B. Inject 20 units of air into the NPH insulin vial. Injecting air into the NPH vial first helps equalize the pressure. A. Inject 10 units of air into the regular insulin vial. This prepares the regular insulin vial for withdrawal without creating a vacuum. C. Withdraw 10 units of regular insulin. After injecting air into the regular insulin vial, withdraw the regular insulin first to avoid contaminating it with the NPH insulin. D. Withdraw 20 units of NPH insulin. Finally, withdraw the NPH insulin after the regular insulin.

A. Explain alternatives to the procedure to the client. B. Discuss the risks of the procedure with the client. C. Confirm that the client is competent to sign for the procedure. D. Inform the client about what will occur during the procedure.

Correct Answer is C

Explanation

A. Explain alternatives to the procedure to the client.
The nurse should provide information about alternative treatments or procedures available to the client, ensuring they have a comprehensive understanding of their options.

B. Discuss the risks of the procedure with the client.
It is crucial for the nurse to communicate the potential risks and complications associated with the procedure to the client, allowing them to make an informed decision.

C. Confirm that the client is competent to sign for the procedure.
Before obtaining informed consent, the nurse should ensure that the client has the mental capacity to understand the information provided, make decisions, and provide consent.

D. Inform the client about what will occur during the procedure.
The nurse should educate the client about the details of the procedure, including what to expect before, during, and after. This information aids in the client's understanding and decision-making process.

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A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B, A, C, D

Explanation

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Correct Answer is C

Explanation

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