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. Flush the tube with water:
This is the correct action to take first. Flushing the tube with water ensures that the tube is clear and functional before administering the bolus enteral feeding.
B. Measure stomach contents:
This is not the first action to take. Before measuring stomach contents, it's important to confirm that the tube is patent and clear by flushing it with water.
C. Elevate the head of the bed:
While elevating the head of the bed is important during and after enteral feedings to reduce the risk of aspiration, it is not the first step. The initial focus should be on verifying the tube's patency.
D. Return gastric content into the gastrostomy tube:
If there is resistance or difficulty flushing the tube, returning gastric contents into the tube may be necessary, but it's not the first action. The first step is to attempt to clear the tube with water.
Correct Answer is B
Explanation
A. Proliferation Phase:
Explanation: This phase involves the formation of new tissue to fill the wound space. It includes granulation tissue formation and wound contraction.
B. Inflammation Phase:
Explanation: This is the initial phase characterized by hemostasis and inflammation, aimed at stopping bleeding and preventing infection. Blood vessels constrict, platelets aggregate, and inflammatory cells arrive at the wound site.
C. Maturation Phase:
Explanation: Also known as the remodeling phase, it involves the remodeling and realignment of collagen fibers and the strengthening of scar tissue.
D. Remodeling Phase:
Explanation: Remodeling and maturation are often considered together as the final stage of wound healing, where collagen fibers reorganize and gain strength.
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