The patient has a large red, blistered area on the left hip.
Which pressure injury stage will be recorded in the patient’s chart?
Stage 2
Stage 4
Stage 3
Stage 1
The Correct Answer is A
Choice A rationale:
Stage 2 pressure injuries are characterized by partial-thickness loss of skin layers involving the epidermis and/or dermis. They present as a red, blistered area, often with an intact or ruptured serum-filled blister. The wound bed is typically moist and may be painful. There is no exposure of underlying bone, tendon, or muscle.
Key features of Stage 2 pressure injuries that align with the patient's presentation:
Red, blistered area: This is a hallmark sign of Stage 2, indicating tissue damage and inflammation in the epidermis and dermis. Large size: The size of the wound suggests more extensive tissue damage, consistent with Stage 2 rather than Stage 1.
Absence of deeper tissue involvement: The absence of exposed bone, tendon, or muscle rules out Stage 3 or 4 pressure injuries.
Rationales for other choices:
Choice B: Stage 4
Stage 4 pressure injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. This is not consistent with the patient's presentation, which does not describe exposed deeper tissues.
Choice C: Stage 3
Stage 3 pressure injuries involve full-thickness tissue loss, but without exposed bone, tendon, or muscle. They often present with a deep crater-like appearance and may have undermining or tunneling. The patient's wound does not exhibit these features, making Stage 3 less likely.
Choice D: Stage 1
Stage 1 pressure injuries are characterized by intact skin with non-blanchable redness over a bony prominence. They do not involve blisters or open wounds. The patient's presentation clearly exceeds the features of Stage 1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Stage 1 pressure injury:
Non-blanchable erythema of intact skin: This means that when you press on the area, the redness does not disappear. It is persistent and remains even after pressure is relieved, unlike other types of skin redness that may blanch temporarily.
Intact skin: This is a crucial characteristic of Stage 1. The skin is not broken or open, differentiating it from more advanced stages.
Commonly over bony prominences: The malleolus, or ankle bone, is a bony prominence that is susceptible to pressure injuries due to its location and potential for prolonged pressure.
Explanation:
Non-blanchable erythema: The description of the redness as "non-blanchable" is the key indicator of a Stage 1 pressure injury. Blanchable erythema, which disappears when pressure is applied, can be due to other causes like inflammation or skin irritation, but non-blanchable erythema signals a deeper issue with the tissue.
Intact skin: The fact that the skin is intact rules out Stages 2, 3, and 4, which all involve some degree of skin breakdown.
Location on a bony prominence: The malleolus is a common site for pressure injuries because it's a bony area that often bears weight, especially in those with limited mobility or those confined to beds or chairs.
Additional Information:
Pressure injuries, also known as pressure ulcers or bed sores, are areas of damage to the skin and underlying tissue caused by prolonged pressure.
They are a common problem in healthcare settings, particularly among patients with limited mobility. Early identification and intervention are crucial to prevent progression to more severe stages.
Correct Answer is C
Explanation
Choice A rationale:
Incorrect dosage form: Metformin is typically administered orally as a tablet or liquid suspension, not as a powder for reconstitution (PO).
Missing route of administration: The medication order does not specify the route of administration, such as oral (PO), intravenous (IV), or intramuscular (IM).
Potential for medication errors: The lack of clarity in the medication order could lead to errors in administration, such as giving the wrong dose or administering the medication by the wrong route.
Choice B rationale:
Incorrect dosage unit: Methotrexate is typically administered in milligrams (mg), not grams (g).
Potential for overdose: The order for 15.0 g of methotrexate is a very high dose that could lead to serious adverse effects, including toxicity and death.
Choice C rationale:
Correctly written: The medication order specifies the drug name (meropenem), the dose (1.0 g), the dosage form (IV), and the route of administration (IV).
Appropriate dosage range: The dose of 1.0 g of meropenem is within the typical dosage range for this antibiotic.
Clear and concise: The medication order is clear, concise, and easy to understand, which helps to reduce the risk of medication errors.
Choice D rationale:
Incorrect: While choices A and B are both incorrect, choice C is a correctly written medication order.
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