A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Full thickness skin loss with visible bone

Full thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed

Intact skin with localized erythema

Answer and Explanation

The Correct Answer is D

A. Full thickness skin loss with visible bone describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in the wound bed describes a stage 2 pressure injury.
D. Intact skin with localized erythema (redness) that does not blanch when pressure is applied is characteristic of a stage 1 pressure injury.

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Correct Answer is C

Explanation

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

A. "Your husband should decide when more medication is needed." B. "Next time you think he needs more medication, call me and I'll push the button." C. "It's a good idea to help make sure your husband can sleep comfortably." D. "Why do you think your husband needs more medication when he is asleep?"

Correct Answer is A

Explanation

A. This response emphasizes the importance of the patient controlling their own pain management. PCA pumps are designed to allow the patient to self-administer pain medication as needed, ensuring they receive the appropriate dose based on their pain levels.
B. This response is inappropriate because it undermines the purpose of a PCA pump, which is to allow the patient to control their own pain relief.
C. While the partner's intention is to help, this response does not address the potential risk of over-sedation and respiratory depression when someone other than the patient administers the medication.
D. This response questions the partner's actions but does not provide clear guidance on the proper use of the PCA pump.

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A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Correct Answer is C

Explanation

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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