A nurse is providing care for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include?

A: Intact skin with localized erythema describes a stage 1 pressure injury, where the skin is not broken but shows signs of redness and irritation. This stage does not involve any loss of skin layers.

B: Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury. At this stage, the injury extends through the full thickness of the skin and exposes fat tissue, but not muscle, bone, or tendon.

C: Partial-thickness skin loss with red tissue in the wound bed is indicative of a stage 2 pressure injury. This stage involves damage to the epidermis and dermis, resulting in a shallow, open wound with a red or pink wound bed. It may also present as an intact or ruptured blister.

D: Full-thickness skin loss with visible bone describes a stage 4 pressure injury. This stage involves extensive destruction, with tissue loss extending to muscle, bone, or supporting structures.

A: A drop in systolic blood pressure of 10 mm Hg (from 140 to 130) does not meet the criteria for orthostatic hypotension, which requires a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure within three minutes of standing.

B: This finding shows a drop in systolic blood pressure from 130 to 110 mm Hg, which is a 20 mm Hg decrease. This meets the criteria for orthostatic hypotension, indicating that the patient may have this condition.

C: A drop in systolic blood pressure of 6 mm Hg (from 126 to 120) does not meet the criteria for orthostatic hypotension. The decrease is not significant enough to confirm the condition.

D: An increase in blood pressure (from 130/64 to 140/70) does not indicate orthostatic hypotension. This finding suggests that the patient’s blood pressure increases upon standing, which is not consistent with orthostatic hypotension.