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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Contacting the health care provider is the most appropriate action because a change in the Doppler sound may indicate a potential complication, such as graft occlusion or compromised blood flow. Immediate assessment and intervention by the health care provider are essential to prevent further complications and ensure the patient's safety.

Choice B reason: Rechecking the pulse in another 30 minutes is not advisable in this situation because it could delay necessary medical intervention. Prompt communication with the health care provider is crucial to address the underlying issue and provide timely care.

Choice C reason: Measuring the ankle-brachial index can provide valuable information about blood flow in the lower extremities, but it is not the immediate priority when a significant change in the Doppler sound is detected. Contacting the health care provider for further assessment and instructions takes precedence.

Choice D reason: Administering an oral anticoagulant is not an appropriate action without the direct instruction from a health care provider. The nurse must first report the change in the Doppler sound to the provider and follow their specific orders regarding medication and treatment.

A. Synthroid B. PTU (Propylthiouracil) C. Tapazole D. Propranolol

Correct Answer is A

Explanation

Choice A reason: Synthroid (levothyroxine) is the most commonly prescribed medication for hypothyroidism. It is a synthetic form of thyroxine (T4), which replaces the deficient hormone in patients with hypothyroidism and helps normalize their thyroid function.

Choice B reason: PTU (Propylthiouracil) is typically used for the treatment of hyperthyroidism, not hypothyroidism. It works by inhibiting the synthesis of thyroid hormones.

Choice C reason: Tapazole (methimazole) is also used for the treatment of hyperthyroidism, similar to PTU. It is not used to treat hypothyroidism.

Choice D reason: Propranolol is a beta-blocker that is used to manage symptoms of hyperthyroidism, such as tremors and palpitations. It does not treat hypothyroidism.

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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?

Nursing Test Bank

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