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 D

Explanation

A. Medications should be diluted as per pharmacy recommendations, not arbitrarily with 10 mL of tap water.
B. The head of the bed should be elevated to at least 30-45 degrees during and after feeding to prevent aspiration.
C. Medications should not be mixed together to avoid interactions unless recommended by the pharmacy.
D. Flushing the NG feeding tube with 30 mL of water immediately following medication administration ensures that the medication has cleared the tube and prevents clogging.

A. "Your husband should decide when more medication is needed." B. "Next time you think he needs more medication, call me and I'll push the button." C. "It's a good idea to help make sure your husband can sleep comfortably." D. "Why do you think your husband needs more medication when he is asleep?"

Correct Answer is A

Explanation

A. This response emphasizes the importance of the patient controlling their own pain management. PCA pumps are designed to allow the patient to self-administer pain medication as needed, ensuring they receive the appropriate dose based on their pain levels.
B. This response is inappropriate because it undermines the purpose of a PCA pump, which is to allow the patient to control their own pain relief.
C. While the partner's intention is to help, this response does not address the potential risk of over-sedation and respiratory depression when someone other than the patient administers the medication.
D. This response questions the partner's actions but does not provide clear guidance on the proper use of the PCA pump.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

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

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?

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

A chronically ill, bedfast patient cared for in the home by family members has a stage II pressure ulcer over the coccyx. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

What screening test is accomplished by performing an Intradermal injection?

A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?