A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
Partial-thickness skin loss.
Necrotic subcutaneous tissue.
Blood-filled blisters.
Exposed bone.
The Correct Answer is B
The correct answer is choice B. Necrotic subcutaneous tissue.
Choice A rationale:
Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.
Choice B rationale:
Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.
Choice C rationale:
Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.
Choice D rationale:
Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Applying petroleum jelly to the nares is not necessary in this situation. Oxygen therapy through a nasal cannula aims to deliver oxygen to the client's respiratory system. Applying petroleum jelly might interfere with the oxygen delivery and is not a standard practice.
Choice B rationale:
Removing the nasal cannula while the client eats reduces the oxygen supply during a time when the body's oxygen demand might increase due to the digestive process. It's important to maintain consistent oxygen therapy, even during meals.
Choice C rationale:
Attaching a humidifier bottle to the base of the flow meter is not necessary for oxygen therapy at 5 L/min via nasal cannula. Humidification is usually needed at higher oxygen flow rates to prevent drying of the mucous membranes.
Choice D rationale:
Securing the oxygen tubing to the bed sheet near the client's head is the correct action. This ensures that the tubing is not pulled or tugged during movement, maintaining a steady flow of oxygen. Placing it near the client's head prevents kinking or tangling of the tubing and allows the client to move without disrupting the therapy.
Correct Answer is A
Explanation
Choice A rationale:
(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.
Choice B rationale:
Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.
Choice C rationale:
Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.
Choice D rationale:
Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.
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