The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.
He states that it is painful.
This is a:

pressure injury.

stage 2.

stage 1.

stage 3.

stage 4. .

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.

Choice D rationale:

Stage 3 pressure injuries involve full-thickness skin loss.

Choice E rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

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Correct Answer is A

Explanation

Choice A rationale:

An unresponsive client who only occasionally changes position is at the highest risk for developing a pressure injury due to prolonged pressure on certain areas of the body.

Choice B rationale:

A client who is alert and responsive and eats 25% of each meal is at lower risk as they are likely to move more frequently.

Choice C rationale:

A client who makes frequent slight changes in position and walks occasionally is at lower risk due to regular movement.

Choice D rationale:

A client who is receiving enteral feeding and can change position independently is at lower risk as they are able to relieve pressure regularly.

A. BMI of 20. B. Peripheral neuropathy. C. Immobility. D. Hypoperfusion. E. Prealbumin level of 16 mg/dL. .

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

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of pressure injuries.

Choice B rationale:

Peripheral neuropathy can lead to decreased sensation, increasing the risk of pressure injuries as the person may not feel discomfort from prolonged pressure.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases the duration of pressure on certain areas of the body.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue damage and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is within the normal range (15-36 mg/dL), so it does not increase the risk of pressure injuries.

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The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients.Which of the following clients should the nurse identify is at the highest risk for developing a pressure injury?

Correct Answer is A

Explanation

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

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

Explanation

While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood.Which is the appropriate action for you to take at this time?

A nurse is preparing to assist with irrigating a wound for a client.Which of the following actions should the nurse plan to take?

When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

Safety factors involved in using an Aquathermia pad unit for a patient include (Select all that apply.)

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

A nurse is collecting data on a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.He states that it is painful.This is a:

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip.
He states that it is painful.
This is a: