The nurse is assessing the patient’s pressure injury and finds that some subcutaneous fat is showing, but no muscle tissue is exposed. What stage is the pressure injury?
A. Stage 3
B. Stage 2
C. Stage 4
D. Stage 1
Answer: A.
This is a Stage 3 (full-thickness) pressure injury because it extends to subcutaneous tissue but not muscle, tendon, or bone. A Stage 4 pressure injury would have muscle, tendon, or bone exposed. A Stage 1 or Stage 2 pressure injury is partial thickness and would not have visible subcutaneous tissue.
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1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline. 2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body. 3. Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest, 4. 1cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension.
Which of the following is NOT accurate regarding the organization and agency efforts to support quality and safety in the health-care system?
A) The U.S. Department of Health and Human Services is the primary agency responsible for protecting health in America. B) The American Nurses Association manages a database of unit-specific nurse-sensitive data known as NDNQI. C) Nonprofit organizations such as the Robert Wood Johnson Foundation and Leapfrog Group all have the singular focus to improve health-care outcomes for the underserved. D) The purpose of the Joint Commission is to provide voluntary accreditation of hospitals and health-care organizations.
During a pelvic examination, a clinician asks the patient to bear down to inspect the vaginal outlet for:
A. Cystocele B. Rectocele C. Prolapsed uterus D. All of the above
The danger of fluid overload developing is a potential problem in the infant receiving an intravenous infusion. For which of the following would you observe?
A) Increased pulse rate and increased blood pressure B) Increased pulse rate and decreased blood pressure C) Decreased pulse rate and decreased blood pressure D) Decreased blood pressure and swelling of the feet