A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?
Full-thickness skin loss with visible bone.
Full-thickness skin loss with visible adipose tissue.
Skin remains intact with localized erythema.
Partial-thickness skin loss with red tissue in the wound bed.
The Correct Answer is C
Choice A rationale
Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.
Choice B rationale
Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.
Choice C rationale
In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
Choice D rationale
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While gastric acid can cause dyspepsia, measuring gastric residual is not primarily done to remove gastric acid.
Choice B rationale
Measuring gastric residual is primarily done to identify delayed gastric emptying. This is important because delayed gastric emptying can lead to complications such as aspiration pneumonia.
Choice C rationale
Gastric residual does not directly determine the patient’s electrolyte balance.
Choice D rationale
While confirming the placement of the NG tube is important, it is not the primary purpose of measuring gastric residual.
Correct Answer is ["35"]
Explanation
Step 1 is: To find out how many mL/hr the nurse should set the infusion pump to deliver, we need to divide the total volume of enteral nutrition (840 mL) by the total time (24 hours).
So, the calculation is: 840 mL ÷ 24 hours = 35 mL/hr Therefore, the nurse should set the infusion pump to deliver 35 mL/hr.
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