Which feature does the nurse associate with a stage 2 pressure ulcer?

Correct Answer: A

Rationale: The correct answer is A: Presence of nonintact skin. In stage 2 pressure ulcers, the skin is partially lost, forming an open wound with a shallow crater. This distinguishes it from stage 1, where only intact but reddened skin is present. Choices B, C, and D are incorrect because they describe features associated with stages 4, 3, and 1 pressure ulcers, respectively. Sinus tracts and extensive tissue damage characterize stage 4 ulcers, while damage to subcutaneous tissues is seen in stage 3 ulcers. Reddened skin over bony prominences is indicative of stage 1 pressure ulcers.

Correct Answer: C

Rationale: The correct answer is C: Isotonic. Solutions with equal solute concentration have the same osmotic pressure, allowing for balanced movement of water in and out of cells. This prevents cells from shrinking or swelling. Volumetric (A) refers to measurement, hypertonic (B) means higher solute concentration, and metabolic (D) pertains to biochemical reactions, making them all unrelated to the concept of equal solute concentration.

Correct Answer: D

Rationale: The correct answer is D because it encompasses all the key differences between first-degree and second-degree burns. A: A first-degree burn affects only the epidermis, while a second-degree burn affects both the epidermis and the dermis. This is correct as first-degree burns are superficial, affecting only the outer layer of the skin, while second-degree burns penetrate deeper into the dermis. B: A first-degree burn is characterized by redness and pain, while a second-degree burn is characterized by blisters and swelling. This is accurate as first-degree burns typically result in redness and pain, whereas second-degree burns involve blister formation and swelling due to damage to deeper skin layers. C: A first-degree burn heals within a few days, while a second-degree burn may take several weeks to heal. This is true as first-degree burns are minor and usually heal quickly, whereas second-degree burns require more time to heal due to the deeper tissue damage. Therefore, by considering all the distinctions

Correct Answer: B

Rationale: The correct answer is B: Obtain the vital signs. Sudden severe upper abdominal pain, diaphoresis, and a very firm abdomen in a patient with a peptic ulcer and NG tube can indicate a perforation or complication requiring immediate assessment. Vital signs can provide crucial information on the patient's condition and guide further interventions. Irrigating the NG tube (A) can worsen the situation if there is a perforation. Giving antacid (C) may not address the underlying issue and delay necessary interventions. Listening for bowel sounds (D) is important but obtaining vital signs takes precedence in this critical situation.

Correct Answer: A

Rationale: The correct answer is A: Assess the client's lung sounds and oxygenation. This is the most appropriate action because Lisinopril, an ACE inhibitor, can cause a side effect of cough due to bradykinin accumulation in the lungs. This cough can indicate potential pulmonary edema or bronchospasm. Assessing lung sounds and oxygenation can help determine the severity of the cough and any respiratory distress. It is crucial to evaluate the client's respiratory status promptly to prevent further complications. Summary of other choices: B: Instructing the client on another antihypertensive is not appropriate without assessing the current situation. C: Obtaining vital signs is important but assessing the respiratory status takes precedence due to potential respiratory distress. D: Reminding the client about the side effect of Prinivil is not sufficient; the focus should be on evaluating the current cough and its impact on the client's respiratory status.