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 C
Explanation
Step 1 is to calculate the amount of amoxicillin in milliliters. Step 2: We know that 250 mg of amoxicillin is in 5 mL.
Step 3: We need to find out how many mL contain 350 mg of amoxicillin. Step 4: Set up a proportion: 250 mg/5 mL = 350 mg/x mL.
Step 5: Cross-multiply and solve for x: 250x = 1750. Step 6: Divide both sides by 250: x = 7 mL2.
Correct Answer is B
Explanation
Choice A rationale
Turning the torso at the waist when reaching for objects can actually increase the risk of back injury. It’s important to keep the back straight and bend at the knees when lifting or reaching for objects.
Choice B rationale
Using ice packs intermittently for 48 hours is a common recommendation for acute lower back pain. Ice can help reduce inflammation and numb the area, providing relief. It’s important to use the ice packs intermittently, not continuously, to avoid frostbite.
Choice C rationale
Using 10 lb arm weights to start strengthening the back muscles is not recommended for someone with acute lower back pain. Heavy lifting can exacerbate the pain and potentially cause further injury. It’s better to start with gentle, low-impact exercises and gradually increase intensity as the back heals.
Choice D rationale
Staying in bed except for toileting during the first 24 hours is not typically recommended for acute lower back pain. While rest is important, prolonged bed rest can actually lead to muscle stiffness and increased pain. It’s generally recommended to stay as active as possible without exacerbating the pain.
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