A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

Stage I Pressure ulcer.

Stage II Pressure ulcer.

Stage IV Pressure ulcer.

Stage II Pressure ulcer.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.

Choice B rationale:

Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.

Choice C rationale:

Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.

Choice D rationale:

Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

The choice "Rectus Femoris" is not the correct answer. The rectus femoris is a muscle located in the thigh and is not a common site for intramuscular injections due to its location and proximity to important structures.

Choice B rationale:

The correct answer is "Vastus Lateralis." Choice B is the correct answer. The vastus lateralis muscle is located on the lateral aspect of the thigh and is a suitable site for intramuscular injections. It is often used in infants and young children or in adults who have limited deltoid muscle mass.

Choice C rationale:

The correct answer is "Dorsogluteal." Choice C is the correct answer. The dorsogluteal muscle, located in the buttocks, has historically been used for intramuscular injections. However, it's important to note that due to the proximity of the sciatic nerve and the potential for incorrect injection technique, this site is used less frequently now.

Choice D rationale:

The choice "Lower abdomen" is not the correct answer. The lower abdomen is not a recommended site for intramuscular injections due to the risk of injuring underlying structures and the potential for subcutaneous injection instead of intramuscular.

Choice E rationale:

The correct answer is "Deltoid." Choice E is the correct answer. The deltoid muscle, located in the upper arm, is commonly used for intramuscular injections, especially for vaccines and smaller medication volumes. However, it has a limited muscle mass and may not be suitable for larger injection volumes.

A. Contact. B. Droplet. C. Standard. D. Airborne.

Correct Answer is A

Explanation

Choice A rationale:

This choice is correct. Hepatitis B is primarily transmitted through contact with infected blood and bodily fluids. Contact precautions are designed to prevent the spread of infections that are transmitted through direct or indirect contact. These precautions include wearing gloves and gowns when in contact with the client or their environment.

Choice B rationale:

Droplet precautions are not appropriate for hepatitis B. Droplet precautions are used for infections that are spread through respiratory droplets, like coughing or sneezing. Hepatitis B is not primarily transmitted through respiratory droplets.

Choice C rationale:

Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and eye protection to prevent the transmission of infections. While these precautions should always be practiced, they are not specifically tailored to hepatitis B, which has its own set of precautions.

Choice D rationale:

Airborne precautions are used for infections that are spread through small respiratory particles that remain suspended in the air for longer periods. Hepatitis B is not transmitted through airborne routes, so airborne precautions are not necessary.

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A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a Medical-Surgical unit is preparing to administer an intramuscular injection to a client. Which of the following sites can the nurse use? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

A nurse is admitting a client who has hepatitis

Correct Answer is A

Explanation

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