The nurse is applying antiembolism stockings to the lower ...

[corkyiscool3328]

The nurse is applying antiembolism stockings to the lower extremities of a client. What is the correct sequence for application of the antiembolism stockings?
 
  1 . Applying the antiembolism stockings
   2 . Taking measurement of the legs for proper size
   3 . Explaining the procedure to the client
   4 . Checking the integrity of the stockings
  A) 1, 2, 3, 4
  B) 2, 1, 4, 3
  C) 3, 2, 1, 4
  D) 4, 3, 2, 1

Question 2

The nurse is assessing a client's wound on admission to the healthcare facility. The client has a loss of epidermis with damage into the dermis that appears as a shallow crater/blister with red/pink wound bed and no sloughing on the right hip.
 
  Based on this information, what stage pressure ulcer should the nurse document in the electronic medical record? A) Stage 1
  B) Stage 2
  C) Stage 3
  D) Stage 4

[aruss1303]

Answer to Question 1

C
Feedback:
The correct sequence for application of the antiembolism stockings is explaining the procedure to the client, taking measurements of the legs for proper size, applying the antiembolism stockings and, checking for the integrity of the stockings.

Answer to Question 2

B
Feedback:
This is stage 2, loss of epidermis with damage into the dermis that appears as a shallow crater/blister with red/pink wound bed and no sloughing. Stage 1 is pressure related alteration of intact skin. In stage 3, subcutaneous tissues are involved and subcutaneous fat may be visible with no bone, tendon, or muscle exposed. Stage 4 is extensive damage to underlying structures, full-thickness tissue loss with exposed bones, tendons, or muscles.