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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.

Choice B rationale:

Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.

Choice C rationale:

Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.

Choice D rationale:

Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.

A. Place the client in airborne isolation. B. Advise the family members not to bring flowers into the room. C. Obtain a sputum sample for culture. D. Place the client on contact precaution.

Correct Answer is A

Explanation

Choice A rationale:

Placing the client in airborne isolation is a priority because measles is highly contagious and spread through airborne droplets. Airborne precautions are necessary to prevent the transmission of pathogens that can remain suspended in the air for longer periods. Measles is known for its high infectivity, and isolating the client in a negative pressure room equipped with HEPA filtration can help prevent the spread of the virus to other patients and healthcare workers.

Choice B rationale:

While advising family members not to bring flowers into the room is a reasonable infection control measure, it is not the priority action in this scenario. The immediate concern is to prevent the spread of the highly contagious measles virus through airborne transmission.

Choice C rationale:

Obtaining a sputum sample for culture is not the priority action in this situation. Measles is a viral infection, and sputum cultures are typically used to identify bacterial infections. Additionally, the primary mode of transmission for measles is through airborne droplets, so preventing its spread takes precedence over obtaining a sputum sample.

Choice D rationale:

Placing the client on contact precaution is not the correct choice for managing measles. Measles is primarily transmitted through the airborne route, so airborne precautions, not contact precautions, are necessary to prevent its transmission.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 Medical-Surgical nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is admitting a client who has measles and a persistent cough. Which of the following actions is a priority for the nurse to take?

Correct Answer is A

Explanation

While preparing to administer the patient's scheduled medications, the nurse does not understand why the client will be receiving one of the prescribed drugs. What action should the nurse take?

A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a client who is worried about the outcome of a laboratory test. The nurse is demonstrating which of the following ethical principles?

A Medical-Surgical nurse is teaching a client about the uses of cranberry juice. Which of the following information should the nurse include in the teaching?

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

A nurse on the Medical-Surgical unit is assessing a patient's wound dressing, and observes a watery light red-pink drainage. The nurse should document this drainage as which of the following?

A nurse on the Cardiovascular unit is completing the patient's history and physical examination. Which of the following information provided by the patient should the nurse consider as subjective data?

A Cardiovascular nurse is giving transdermal Fentanyl as per ordered to the patient. What is an important safety measure to take when changing and applying a transdermal patch?

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?