A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which statement should the nurse use to describe a stage 3 pressure ulcer?
Full-thickness tissue loss extending to underlying support structures
A deep crater without visible bone, tendon, or muscle
A shallow, ruptured or intact skin blister without slough
Unbroken skin with un-blancheable erythema
The Correct Answer is B
Choice A rationale
Full-thickness tissue loss extending to underlying support structures such as muscle, tendon, or bone is characteristic of a stage 4 pressure ulcer, not a stage 312.
Choice B rationale
A stage 3 pressure ulcer involves full-thickness skin loss and may appear as a deep crater. There may be damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This description matches the statement in Choice B, making it the correct answer.
Choice C rationale
A shallow, ruptured or intact skin blister without slough is more indicative of a stage 2 pressure ulcer. In a stage 2 pressure ulcer, there is partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
Choice D rationale
Unbroken skin with un-blancheable erythema is characteristic of a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin is not broken, but it has redness that does not lighten (or blanch) when you press on it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with
each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.
Correct Answer is B
Explanation
Choice A rationale
While it is important to ensure that restraints are not too tight, the issue in this scenario is not related to the tightness of the restraints.
Choice B rationale
Restraints should be tied with a slipknot to allow for quick release if necessary. A double knot may be difficult to untie quickly in an emergency.
Choice C rationale
Restraint straps should not be tied to the side rails. If the side rails are lowered, the restraints could become too loose.
Choice D rationale
The padding under the wrist restraints should not be removed. The padding helps to prevent skin damage and increase the comfort of the patient.
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