A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?
Stage 2
Stage 1
Stage 3
Stage 4
The Correct Answer is C
Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.
Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.
Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.
Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While blood glucose monitoring is essential for patients receiving TPN, it is not specifically necessary to obtain samples from a central line. Blood glucose levels can be monitored through peripheral blood samples.
Choice B reason: There is actually an increased risk of infection with central lines compared to peripheral lines due to the invasive nature of central line placement and its location. Proper aseptic technique is critical to minimize this risk.
Choice C reason: The hypertonic solution will be more rapidly diluted when given through a central line. This is a critical point because the central veins have a higher blood flow and larger volume, which helps to quickly dilute the hypertonic TPN solution. This reduces the risk of phlebitis and damage to the smaller peripheral veins, making central lines more suitable for infusing highly concentrated solutions like 25% dextrose.
Choice D reason: While a central line can allow for the rapid administration of infusions, this is not the primary reason for its use with TPN. The key factor is the dilution of the hypertonic solution, as central lines handle high osmolarity solutions better than peripheral veins.
Correct Answer is A
Explanation
Choice A reason: Administering antiemetics before chemotherapy is an effective intervention to help manage Sarah's nausea. Antiemetics can prevent or reduce the severity of nausea and vomiting associated with chemotherapy, making it easier for patients to tolerate treatment and maintain their nutritional status.
Choice B reason: Encouraging carbonated beverages is not a recommended intervention for managing nausea. Carbonated beverages can sometimes worsen nausea due to their acidity and carbonation.
Choice C reason: Recommending three large meals and two small snacks daily is not the best approach for managing nausea. Smaller, more frequent meals are generally more effective in preventing nausea and ensuring adequate calorie intake. Large meals can be overwhelming and may exacerbate nausea.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.