A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

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.

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.