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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is not the appropriate method for disposing of a dressing saturated with blood and purulent drainage. Blood and purulent drainage are considered potentially infectious materials, and they should be handled as biohazardous waste to prevent the spread of infection.

Choice B rationale:

This is the correct choice. When dealing with potentially infectious materials such as blood and purulent drainage, it's essential to dispose of them in a biohazardous waste container. This specialized container is designed to contain potentially infectious materials and prevent their spread, thereby protecting both healthcare workers and the environment.

Choice C rationale:

Discarding the dressing in the bedside trash receptacle is not the recommended approach for disposing of materials that are contaminated with blood and purulent drainage. Simply discarding it in the regular trash increases the risk of infection transmission and is not compliant with proper infection control practices.

Choice D rationale:

Double-bagging the dressing in clear bags and labeling it "biohazard" is a good practice to ensure proper containment. However, it's not the most comprehensive method of disposal. Placing the dressing in a dedicated biohazardous waste container is a more secure and standardized method for disposing of potentially infectious materials.

A. "My child must be free from nits before returning to school.” B. "Toys that can't be dry cleaned or washed must be thrown out.” C. "I will treat all the family members to be on the safe side.” D. "All recently used clothing, bedding, and towels must be washed in hot water.”

Correct Answer is D

Explanation

Choice A rationale:

Requiring the child to be free from nits before returning to school might not be an accurate understanding of the situation. Nits are the eggs of head lice and may remain attached to the hair even after effective treatment. The presence of live lice is a more crucial factor to consider.

Choice B rationale:

Throwing out toys that can't be dry cleaned or washed is an unnecessary and extreme measure. Head lice do not survive long away from the human scalp, so the risk of transmission through inanimate objects like toys is minimal. Thoroughly cleaning and vacuuming the environment is more effective.

Choice C rationale:

Treating all family members is indeed a prudent approach. Head lice can spread easily within households, especially among close contacts. Treating everyone helps prevent re-infestation and disrupts the lice life cycle.

Choice D rationale:

Washing recently used clothing, bedding, and towels in hot water is a correct understanding of how to manage head lice. The high temperature kills lice and their eggs. It is an essential step in preventing the spread of lice and re-infestation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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