A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

Stage I Pressure Ulcer

Stage II Pressure Ulcer

Stage IV Pressure Ulcer

Stage III Pressure Ulcer

Answer and Explanation

The Correct Answer is B

Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: Taking the client to the toilet when they have the urge to defecate promotes a natural bowel pattern and is an essential aspect of bowel training.
Choice B rationale: Timing toilet visits based on a regular schedule may be part of a bowel training program, but waiting for the client to have the urge is more effective.
Choice C rationale: Timing toilet visits with meals may be part of a bowel training program, but taking the client when they have the urge is more effective.
Choice D rationale: Waiting for the client to experience abdominal cramping may lead to delayed toileting and is not recommended in a bowel training program.

A. Lung sounds and chest x-ray B. Bowel sounds and routine urinalysis C. Lung sounds and sputum sample D. Bowel sounds and stool sample

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

Correct Answer is A

Explanation

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

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

The patient is receiving 30 mg of citalopram daily for depression. Citalopram is available in 20 mg scored tablets. How many tablets should be administered? (Round to the nearest tenth.)

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic. Isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?