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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Immobility can lead to pressure ulcers due to prolonged pressure on bony prominences.
B. Polyuria is not a common complication of immobility.
C. Diarrhea is not typically associated with immobility; constipation is more common.
D. Immobility can cause contractures of the extremities due to muscle shortening and tightening.
E. Crackles in the lungs can occur due to fluid accumulation and reduced lung expansion associated with immobility.

A. Inform the client that this drug combination is most effective if the ginkgo biloba is taken twice daily. B. Inform the client that memory problems following valve replacement surgery are common, but temporary. C. Instruct the client that ginkgo biloba interacts with anticoagulant drugs and then check for bruising or bleeding. D. Instruct the client to keep a record of episodes of forgetfulness or memory disturbances to monitor effectiveness.

Correct Answer is C

Explanation

A. Advising a specific dosing regimen for ginkgo biloba without addressing safety concerns is not appropriate.
B. While memory problems may occur post-surgery, addressing the interaction between ginkgo biloba and warfarin is more urgent.
C. Ginkgo biloba can interact with anticoagulant drugs like warfarin, increasing the risk of bleeding. The nurse should instruct the client about this interaction and check for signs of bruising or bleeding.
D. Keeping a record of memory disturbances does not address the immediate safety concern of the interaction between ginkgo biloba and warfarin.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

Correct Answer is C

Explanation

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 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 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?

A nurse is providing teaching to a client who has asthma and a new prescription for an Inhaled corticosteroid (beclomethasone). Which of the following instructions should the nurse provide?

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

What is the preferred IM injection site for a 1-year-old?

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an Indication that the client needs further teaching?

The nurse accidentally administers 15 mg of morphine IM to a client who had been given another dose of morphine 15 mg IM about 30 minutes earlier. What action should the nurse be prepared to take?