A nurse begins her shift and is completing her first turn of the night. While turning, she also assesses her patient's skin. When she turns her patient she finds the following wound on her coccyx. How should she document the following wound? (The base of the wound is muscle, with some subcutaneous tissue)

Stage III Pressure Ulcer

Stage IV Pressure Ulcer

Stage II Pressure Ulcer

Unstageable Ulcer

Answer and Explanation

The Correct Answer is B

Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.

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Correct Answer is B

Explanation

Choice A rationale: Elevating the head of the bed is not the recommended action when moving a client up in bed.
Choice B rationale: Having the client fold the arms across the chest is not the primary action when moving a client up in bed.
Choice C rationale: Asking another nurse about the plan of care is not necessary in this situation and does not directly address the action needed when moving the client.
Choice D rationale: Maintaining a pillow under the client's head helps provide comfort and support during the movement.

A. Request a prescription for the insertion of an indwelling urinary catheter. B. Apply a moisture barrier ointment to the client's skin C. Clean the client's skin and perineum with hot water after each episode of incontinence. D. Check the client's skin every 8 hr for signs of breakdown.

Correct Answer is B

Explanation

Choice A rationale: Inserting an indwelling urinary catheter is an invasive intervention and should be reserved for specific indications. It does not prevent skin breakdown.
Choice B rationale: Applying a moisture barrier ointment to the client's skin helps protect the skin from the harmful effects of urine and prevents breakdown.
Choice C rationale: Cleaning the client's skin and perineum with hot water after each episode of incontinence can lead to skin irritation and breakdown.
Choice D rationale: Checking the client's skin every 8 hours is not sufficient to prevent skin breakdown. Continuous assessment and prompt intervention are needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Correct Answer is B

Explanation

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is B

Explanation

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

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