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

Explanation

A. Diarrhea:
Explanation: Vomiting is more likely to be associated with dehydration than diarrhea. While vomiting and diarrhea can both lead to fluid loss, dehydration is a more immediate concern.

B. Dehydration:
Explanation: This is correct. Vomiting can lead to a significant loss of fluids, and dehydration is a potential complication. It's important to monitor the client's fluid balance, provide oral rehydration solutions or intravenous fluids as needed, and address the underlying cause of vomiting.

C. Urinary frequency:
Explanation: While dehydration can lead to decreased urine output, urinary frequency is not a typical complication of vomiting. Dehydration often results in decreased urine production.

D. Peripheral edema:
Explanation: Peripheral edema is not a direct complication of vomiting. It is more commonly associated with conditions such as heart failure or renal issues.

A. Check the gastric residual every 8 hr. B. Change the feeding bag every 24 hr. C. Flush the tube with sterile sodium chloride solution every 2 hr. D. Position the head of the client's bed at 15.

Correct Answer is ["B"]

Explanation

Correct answer: B

A. Check the gastric residual every 8 hr:
Explanation:It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.

B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.

C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation:While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.

D. Position the head of the client's bed at 15 degrees:
Explanation:To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.

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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

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Correct Answer is B

Explanation

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Correct Answer is ["B"]

Explanation

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