A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

stage I

stage II

stage III

stage IV

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.

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Correct Answer is D

Explanation

The correct answer is choice D. Gather new sterile supplies and start the procedure over.

In order to maintain surgical asepsis during a urinary catheterization procedure, the nurse must ensure that all equipment used is sterile and that there is no contamination of the equipment during the procedure. If the catheter is contaminated, the nurse should stop the procedure, gather new sterile supplies, and start the procedure over to prevent the introduction of bacteria into the urinary tract. Reporting the incident and apologizing to the client are important, but not the first priority in maintaining surgical asepsis. The fact that the client is on antibiotics does not change the need for sterile technique during the procedure.

A. Tertiary B. Primary C. Quaternary D. Secondary

Correct Answer is A

Explanation

The correct answer is choice A, tertiary.

Tertiary prevention aims to improve quality of life and reduce the negative impact of a chronic illness or disability, such as helping the man regain lost function after a stroke. Occupational therapy is a common intervention in tertiary prevention, as it focuses on helping patients adapt to their limitations and develop compensatory strategies to perform daily activities.

Primary prevention aims to prevent a disease or injury before it occurs, such as immunizations or health education to prevent stroke risk factors. Secondary prevention aims to detect and treat a disease in its early stages to prevent complications, such as screening for high blood pressure or high cholesterol levels. Quaternary prevention aims to reduce the harm caused by unnecessary or excessive healthcare interventions, such as avoiding overprescribing medications.

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A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

Correct Answer is D

Explanation

A 54-year-old man is participating in occupational therapy following a strokecausing right-sided weakness. What level of health promotion is being exhibited?

Correct Answer is A

Explanation

Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

A nurse is interviewing a newly admitted patient. What question would best exhibit cultural competence?

A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

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A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

A nurse is providing education to a client diagnosed with insomnia. What sleeppromoting techniques would the nurse suggest to help the client's condition? Select all that apply.

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?