Author Question: On assessment a nurse notes that a patient's skin is reddened with a small abrasion. The nurse most ... (Read 37 times)

ghost! · **on:** Jul 22, 2018

On assessment a nurse notes that a patient's skin is reddened with a small abrasion. The nurse most correctly will classify this ulcer formation as what stage?

A. I
B. II
C. III
D. IV

Question 2

A patient has a morphine sulfate epidural catheter in place for postoperative pain control. When the nurse enters the room, the patient complains of pain. The nurse's first response is to:

A. stop the infusion.
B. call the physician or health care provider immediately.
C. ask the patient to describe the pain.
D. speak to the patient in a calming tone to reduce anxiety.

Carliemb17 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Stage I is an observable pressure ulcer with warm/cool skin temperature, firm or boggy tissue consistency, sensation of pain or itching. Stage III is loss of skin involving damage or necrosis, presenting as a deep crater with or without undermining of surrounding tissues. Stage IV is a full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or tendon/joint capsule. Undermining and sinus tracts are also present.

Answer to Question 2

C
Nurses need to assess the patient first. Next, assess the lines, catheter, and infusion pump. Notify the physician or health care provider or follow protocols should a problem exist. Speaking in a calm voice demonstrates caring behavior.