A nurse assesses a patient's heels for skin breakdown and notes that both heels have a reddened area that does not blanch. The nurse should document the presence of a pressure ulcer in stage:
A) I
B) II
C) III
D) IV
Ans: A
Feedback: A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion. A stage II pressure ulcer exhibits a break in the skin through the epidermis or the dermis. Stage III extends into the subcutaneous tissue, while Stage IV extends into the muscle or bone.
You might also like to view...
How does the epidermal layer of the integument help to maintain homeostasis? Select all that apply
A) It kills bacteria. B) It restricts water loss. C) It allows all bacteria to escape. D) It protects against microbes. E) It protects against radiation. F) It protects against ultraviolet light exposure. G) It filters microbes.
Which pt care activity can be delegated by the RN to unlicensed assistive personnel?
a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises
Examples of illnesses caused by viruses are
A. syphilis and gonorrhea. B. AIDS and hepatitis. C. malaria and amebiasis. D. ringworm and athlete's foot.
What would a patient from Norway use to colds? Select all that apply
1. Hot milk sprinkled with ginger 2. Shot of whiskey 3. Glass of warm wine 4. Hot peppermint tea