A nurse is completing an admission assessment of a client. Which of the following findings should the nurse identify as a stage 2 pressure injury?
A defined area of cool, boggy skin.
A shallow crater involving the epidermis.
Reddened area that does not blanch.
Undermining or tunneling of the skin.
The Correct Answer is B
Choice A rationale:
A defined area of cool, boggy skin is not indicative of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, usually appearing as a shallow open ulcer with a red-pink wound bed, without slough or bruising.
Choice B rationale:
A shallow crater involving the epidermis is characteristic of a stage 2 pressure injury. It presents as a partial-thickness skin loss with the loss of the epidermis, and the wound may be superficial and appear as an abrasion, blister, or shallow ulcer.
Choice C rationale:
The reddened area that does not blanch is more indicative of an early-stage pressure injury (Stage 1). In Stage 1, the skin remains intact, but there is non-blanch-able erythema indicating damage to the skin and underlying tissue.
Choice D rationale:
Undermining or tunneling of the skin is not specific to stage 2 pressure injuries. These features may be observed in more advanced stages of pressure injuries, such as stages 3 and 4, where there is full-thickness skin loss with damage to the subcutaneous tissue and underlying structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
10 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 1 hour. However, the question asks for the rate at which to administer 10 mEq over 1 hour, which means the total volume should be 100 mL/hr.
Choice B rationale:
50 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 2 hours. However, the question specifies 1 hour, so the rate should be higher.
Choice C rationale:
This is the correct answer. To administer 10 mEq of potassium chloride in 100 mL over 1 hour, the infusion pump should be set to deliver 100 mL/hr.
Choice D rationale:
500 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 10 minutes (1/6th of an hour). However, the question specifies 1 hour, so the rate should be much lower.
Correct Answer is C
Explanation
Answer: C. The nurse declines to inform a client's neighbor about the client's prognosis.
Rationale:
A) The nurse files an incident report regarding a medication error:
Filing an incident report is crucial for patient safety and quality improvement but primarily serves organizational processes. It helps identify and address systemic issues to prevent future errors, but it is not a direct act of advocacy for the individual client.
B) The nurse provides wound care to a client at the time promised to the client:
Providing timely care demonstrates reliability and respect for the client's needs, which is an important aspect of nursing care. However, this action alone does not constitute advocacy, as it is more about fulfilling professional responsibilities and maintaining trust.
C) The nurse declines to inform a client's neighbor about the client's prognosis:
Declining to share confidential information with a neighbor is a direct act of advocacy. It protects the client's right to privacy and confidentiality, ensuring that sensitive health information is disclosed only to authorized individuals. Upholding these ethical standards is a fundamental aspect of advocating for the client's rights and dignity.
D) The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:
Referring a client to palliative care is an important aspect of providing holistic and compassionate care, but it is a broader action related to care coordination rather than a specific advocacy action in the context of maintaining client confidentiality and rights.
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