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 C

Explanation

Choice A rationale:

Lillian Wald is known for founding the Henry Street Settlement in New York and for her work in public health nursing and social reform, but she is not specifically associated with keeping records on sanitation techniques and their effects on health.

Choice B rationale:

Clara Barton is renowned for establishing the American Red Cross and her humanitarian efforts during the Civil War. While she contributed significantly to healthcare, her focus was not on keeping records on sanitation techniques and their effects.

Choice C rationale:

Florence Nightingale, the founder of modern nursing, is the nurse who kept records on sanitation techniques and their effects on health. She is known for her work during the Crimean War, where she improved sanitation and hygiene practices in healthcare settings, leading to significant improvements in patient outcomes.

Choice D rationale:

Mary Nutting was an influential figure in nursing education, but she is not primarily recognized for keeping records on sanitation techniques and their effects. Her contributions were more related to curriculum development and nursing education.

A. Petechiae on the chest. B. Increased anteroposterior diameter of the chest. C. Oxygen saturation level 96%. D. Respiratory alkalosis.

Correct Answer is B

Explanation

The correct answer is choice B. Increased anteroposterior diameter of the chest.

Choice A rationale:

Petechiae on the chest (Choice A) are tiny red or purple spots that appear on the skin due to small blood vessel breakage. They are not typically associated with COPD and emphysema. Petechiae are more often related to conditions like thrombocytopenia or certain infections, where blood clotting is impaired.

Choice B rationale:

Increased anteroposterior diameter of the chest, often referred to as "barrel chest," is a characteristic finding in clients with COPD and emphysema. This occurs due to the hyperinflation of the lungs and the loss of elasticity in the lung tissues, which causes the chest to become rounded and the ribs to be positioned more horizontally.

Choice C rationale:

An oxygen saturation level of 96% (Choice C) is within the normal range for oxygen saturation. However, while it's important for clients with COPD to maintain adequate oxygen levels, this value doesn't specifically correlate with the client's symptoms of a wet cough and occasional shortness of breath.

Choice D rationale:

Respiratory alkalosis (Choice D) involves an increase in blood pH due to decreased levels of carbon dioxide (hypocapnia) caused by hyperventilation. While respiratory alkalosis can occur in clients with COPD due to compensatory hyperventilation, it is not a direct assessment finding related to the client's symptoms of a wet cough and occasional shortness of breath.

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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

Which nurse kept records on sanitation techniques and the effects on health?

Correct Answer is C

Explanation

A nurse on a Medical-Surgical unit is performing an assessment on a client who has COPD with emphysema. The client reports that he has a frequent wet cough and is occasionally short-of-breath. The nurse should anticipate which of the following assessment findings for this client?

Correct Answer is B

Explanation

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