A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

Stage I

Stage II

Stage III

Stage IV

Answer and Explanation

The Correct Answer is A

A. Stage I. A Stage I pressure ulcer is characterized by intact skin with non-blanchable erythema. The affected area may feel warmer or firmer than surrounding skin.

B. Stage II. A Stage II pressure ulcer involves partial-thickness skin loss, often presenting as a shallow open ulcer or intact/blistered skin. Since the skin is still intact in this scenario, it is not Stage II.

C. Stage III. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle. This does not match the description of an intact but reddened area.

D. Stage IV. A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. This is much more severe than the described case.

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Correct Answer is B

Explanation

A. Tophi deposits and podagra: These findings are associated with gout, not osteoarthritis. Tophi are urate crystal deposits, and podagra refers to gout affecting the big toe.

B. Heberden's nodes and Bouchard's nodes: Heberden’s nodes are bony growths at the distal interphalangeal (DIP) joints, while Bouchard’s nodes affect the proximal interphalangeal (PIP) joints. These are characteristic of osteoarthritis.

C. Ulnar deviation and joint subluxation: Ulnar deviation and joint subluxation are commonly seen in rheumatoid arthritis, not osteoarthritis.

D. Swan-neck deformity and Boutonnière deformity: These deformities are typical of rheumatoid arthritis, not osteoarthritis.

A. Initiate fluid resuscitation. B. Insert an indwelling urinary catheter. C. Maintain the airway. D. Medicate for pain.

Correct Answer is C

Explanation

A. Initiate fluid resuscitation. Fluid resuscitation is critical to prevent hypovolemic shock, but airway maintenance takes precedence, especially in burns involving the chest and upper body.

B. Insert an indwelling urinary catheter. Urinary catheter insertion is important for monitoring urine output and assessing renal function, but it is not the first priority.

C. Maintain the airway. Burns to the chest, neck, and face increase the risk of airway edema and compromise. The nurse should assess for signs of inhalation injury, hoarseness, or stridor and prepare for early intubation if necessary.

D. Medicate for pain. Pain management is important but is not the highest priority in the resuscitation phase when securing the airway and preventing hypoxia are more critical.

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A nurse is assessing a bedridden patient and notes a reddened area on the sacrum that does not blanch when pressed. The skin is intact. Based on this finding, which stage of pressure ulcer should the nurse document?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

Correct Answer is C

Explanation

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