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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

No explanation

A. Constipation B. Diarrhea C. Electrolyte imbalance D. Delayed gastric emptying

Correct Answer is B

Explanation

Choice A rationale

Constipation is not typically resolved by diluting enteral feeding formula.

Choice B rationale

Diarrhea can be a common side effect of enteral feeding, and diluting the formula can help manage this.

Choice C rationale

While electrolyte imbalance can occur with enteral feeding, diluting the formula is not typically done to resolve this issue.

Choice D rationale

Delayed gastric emptying is not typically resolved by diluting enteral feeding formula.

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A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D"]

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Correct Answer is B

Explanation

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