Author Question: The nurse notes that the patient's skin is reddened, with a small intact serum-filled blister. How ... (Read 128 times)

Redwolflake15 · **on:** Jul 22, 2018

The nurse notes that the patient's skin is reddened, with a small intact serum-filled blister. How should the nurse classify this stage of ulcer formation?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

Question 2

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication.

Which of the following actions should the nurse complete first? a. Return to the room to check and assess the patient.
b. Administer the antidote to the patient immediately.
c. Alert the charge nurse that a medication error has occurred.
d. Complete proper documentation of the medication error in the patient's chart.

jesse.fleming · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B

Feedback
A A stage I pressure ulcer is intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The description is not consistent with a stage I pressure ulcer.
B The description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial thickness, loss of dermis presenting as a shallow open ulcer with a reddish pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.
C A stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible, but there is no exposure of bone, tendon, or muscle. Slough may be present but does not obscure the depth of tissue loss. It may include undermining tunnelling. The description is not consistent with a stage III pressure ulcer.
D A stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough eschar may be present on some parts of the wound bed. The description is not consistent with a stage IV pressure ulcer.

Answer to Question 2

A
The nurse's first priority is to establish the safety of the patient by assessing the patient. Second, notify the charge nurse and the physician. Administer antidote if required. Finally, the nurse needs to complete proper documentation.