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 A

Explanation

Choice A rationale:

This choice is correct. Hepatitis B is primarily transmitted through contact with infected blood and bodily fluids. Contact precautions are designed to prevent the spread of infections that are transmitted through direct or indirect contact. These precautions include wearing gloves and gowns when in contact with the client or their environment.

Choice B rationale:

Droplet precautions are not appropriate for hepatitis B. Droplet precautions are used for infections that are spread through respiratory droplets, like coughing or sneezing. Hepatitis B is not primarily transmitted through respiratory droplets.

Choice C rationale:

Standard precautions involve the use of protective barriers such as gloves, gowns, masks, and eye protection to prevent the transmission of infections. While these precautions should always be practiced, they are not specifically tailored to hepatitis B, which has its own set of precautions.

Choice D rationale:

Airborne precautions are used for infections that are spread through small respiratory particles that remain suspended in the air for longer periods. Hepatitis B is not transmitted through airborne routes, so airborne precautions are not necessary.

A. Pigeon. B. Funnel. C. Kyphotic. D. Barrel.

Correct Answer is D

Explanation

Choice A rationale:

The choice "Pigeon" is not the correct answer. Pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs. This condition is not associated with chronic bronchitis.

Choice B rationale:

The choice "Funnel" is not the correct answer. Funnel chest, or pectus excavatum, is a deformity where the sternum is sunken into the chest. It is not the expected chest shape in chronic bronchitis.

Choice C rationale:

The choice "Kyphotic" is not the correct answer. Kyphosis refers to an excessive outward curvature of the thoracic spine, leading to a rounded upper back appearance. This is not the typical chest shape seen in chronic bronchitis.

Choice D rationale:

The correct answer is "Barrel." Choice D is the correct answer. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airway inflammation and narrowing. Over time, this can lead to air trapping in the lungs and an increase in the anteroposterior diameter of the chest. This results in a barrel-shaped chest appearance, where the chest appears rounded and the ribs are more horizontal. This adaptation allows for increased lung capacity to accommodate for the compromised airflow in patients with chronic bronchitis.

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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?

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