A nurse is collecting data on a client who has a stage 1 pre... | ATI PN Custom Fundamentals CH 38

Practice Question

A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Answer Choices:

A. Full thickness skin loss with visible adipose tissue.

B. Full thickness skin loss with visible bone.

C. Intact skin with localized erythema. ✓ Correct Answer

D. Partial-thickness skin loss with red tissue in the wound bed.

Correct Answer:

Intact skin with localized erythema.

Rationale:

🔴 A stage 1 pressure injury is characterized by intact skin with non-blanchable redness (erythema) over a localized area, usually over a bony prominence.

🔴 The area may be painful, firm, soft, or warmer or cooler compared to adjacent tissue.

🔴 Full-thickness skin loss with adipose tissue describes stage 3.

🔴 Exposure of bone describes a stage 4 pressure injury.

🔴 Partial-thickness skin loss with red tissue is consistent with stage 2.

Want to practice more questions like this?

This question is from ATI PN Custom Fundamentals CH 38 which contains 50 questions.

Start Full Exam View Exam Details

More Questions from This Exam

A nurse performing a right eye irrigation will position the patient:

Answer Choices:

A. Supine with the head tilted toward the right eye.

B. Upright with the head tilted toward the left eye.

C. Upright with the head hyperextended.

D. Supine with the head hyperextended.

View Full Question

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?

Answer Choices:

A. Leave it until the end of the shift.

B. Remove the drain.

C. Empty the reservoir.

D. Notify the surgeon about the blood loss.

View Full Question

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

Answer Choices:

A. Moisten it with povidone iodine.

B. Pull it off using slow, steady pressure.

C. Add normal saline to loosen it.

D. Leave it in place and cover it with new, wet dressings.

View Full Question

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

Answer Choices:

A. From the left to the right across the wound.

B. From the outer abdomen toward the wound.

C. In a circular motion around the wound, circling to the outside.

D. Directly over the wound.

View Full Question

When preparing to change a sterile dressing over an incision, it is most important to remember to:

Answer Choices:

A. Remind him to remain very still during the procedure.

B. Place a discard bag close to the wound.

C. Change gloves after removing the old dressing.

D. Refrain from talking while the wound is uncovered.

View Full Question

View All 50 Questions

From Exam

ATI PN Custom Fundamentals CH 38

50 Questions

View Full Exam Start Practicing

Question Details

Category: LPN - Nursing Exam(s)
Subcategory: ATI Exams
Domain: FUNDAMENTALS OF NURSING PN
Answer Choices: 4

NursingSprint

Practice Question

A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer:

Rationale:

Want to practice more questions like this?

More Questions from This Exam

A nurse performing a right eye irrigation will position the patient:

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?

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

When preparing to change a sterile dressing over an incision, it is most important to remember to:

From Exam

ATI PN Custom Fundamentals CH 38

Question Details

Was this question helpful?

Share your thoughts

Comments (0)

Search Resources, Exams, Questions, Notes & Flashcards

Access Restricted:

Practice Question

A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer:

Rationale:

Want to practice more questions like this?

More Questions from This Exam

A nurse performing a right eye irrigation will position the patient:

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?

The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed. The nurse's most beneficial intervention would be to:

The nurse is performing a dry sterile dressing change for an abdominal wound. The nurse should use a swab to clean:

When preparing to change a sterile dressing over an incision, it is most important to remember to:

From Exam

ATI PN Custom Fundamentals CH 38

Question Details

Was this question helpful?

Share your thoughts

Comments (0)