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.

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Correct Answer is B

Explanation

Choice A rationale: Carrying an air-filled ball while wading through the water across the width of a pool is an isotonic exercise.
Choice B rationale: Contracting the gluteal muscles while holding a simple yoga pose is an isometric exercise.
Choice C rationale: Walking at a rate of 3 miles (5 km)/hour around a racetrack is an isotonic exercise.
Choice D rationale: Sitting in a chair with a low weight on the side and lifting the knee to the seat level of the chair is an isotonic exercise.

A. Encourage fluid intake B. Reduce fluid intake C. Alert the healthcare provider of possible infection D. No action is required

Correct Answer is A

Explanation

Choice A rationale: Dark yellow urine may indicate concentrated urine, and encouraging fluid intake helps dilute the urine, promoting kidney function and preventing dehydration.
Choice B rationale: Reducing fluid intake is not appropriate based solely on the color of the urine. It is essential to assess overall hydration status.
Choice C rationale: Dark yellow urine alone does not necessarily indicate infection. Other symptoms and laboratory tests would be needed for a diagnosis.
Choice D rationale: Taking no action is not appropriate when the color of urine suggests dehydration. Assessing and addressing hydration status are important.

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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

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?

Correct Answer is B

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?

Correct Answer is A

Explanation

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?

Ordered: Morphine sulfate 12 mg IM Available: Morphine sulfate 15 mg/mL How many mL will you administer?

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