A paraplegic patient is admitted to the hospital for intensive management of an open, infected pressure ulcer on the left buttock at the prominence of the ischial tuberosity. The initial assessment of the patient's pressure ulcer indicates that it is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The wound is a full thickness ulcer, has some slough present and extends through the dermis into the subcutaneous tissue. No exposed muscle, tendons, ligaments, cartilage, or bones present. The nurse classifies the pressure ulcer as

Stage II

Stage I

Stage III

Stage IV

Answer and Explanation

The Correct Answer is C

A. Stage II pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
B. Stage I pressure ulcers are characterized by intact skin with non-blanchable redness.
C. Stage III pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
D. Stage IV pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle.

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Correct Answer is C

Explanation

A. The blood must be checked by two licensed professionals, not an assistant personal (AP).
B. Blood should be infused within 4 hours to reduce the risk of bacterial contamination.
C. The nurse should remain with the client for the first 15 minutes of the transfusion to monitor for any immediate adverse reactions.
D. Pre-medicating with an antiemetic is not a standard practice unless specifically indicated by the client's history or condition.

A. Enteral B. Topical C. Intravenous D. Intramuscular

Correct Answer is C

Explanation

A. Enteral administration involves the gastrointestinal tract, which has a slower absorption rate.
B. Topical administration involves absorption through the skin, which is also slower.
C. Intravenous (IV) administration delivers medication directly into the bloodstream, providing the fastest rate of absorption.
D. Intramuscular (IM) administration is faster than enteral and topical but slower than intravenous.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption?

Correct Answer is C

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

A client tells a nurse that she is considering using herbal supplements in addition to her prescription medications. What would be the nurse's best response?

Which of the following are examples of low-risk complementary and alternative therapies that nurses can use with their clients?

What screening test is accomplished by performing an Intradermal injection?

What technique will the nurse implement to assist the postoperative patient to cough?

A nurse is caring for a client who has a large lower leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?