A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Deep Tissue Injury

Stage III Pressure Ulcer

Unstageable Ulcer

Stage IV Pressure Ulcer

Answer and Explanation

The Correct Answer is A

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

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Correct Answer is D

Explanation

Choice A rationale: Lung sounds and chest x-ray are not directly relevant to assessing suspected food poisoning.
Choice B rationale: Routine urinalysis is not directly relevant to assessing suspected food poisoning.
Choice C rationale: Lung sounds and sputum sample are not directly relevant to assessing suspected food poisoning.
Choice D rationale: Bowel sounds and stool sample are relevant to assessing gastrointestinal symptoms associated with food poisoning.

A. Bacteria B. Parasites C. Steatorrhea D. Blood

Correct Answer is D

Explanation

Choice A rationale: The stool test for occult blood is not primarily designed to detect bacteria.
Choice B rationale: Parasites are not typically detected through a stool test for occult blood.
Choice C rationale: Steatorrhea refers to the presence of excess fat in the stool and is not the primary focus of a stool test for occult blood.
Choice D rationale: The purpose of the stool test for occult blood is to check for the presence of blood in the stool, which may not be visible to the naked eye. This can be an indicator of gastrointestinal bleeding.

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A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Correct Answer is D

Explanation

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