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. Stiffness in the lower extremities can occur but is not a primary complication of immobility.
B. Difficulty moving the upper extremities is a result of the stroke, not immobility.
C. A reddened area over the sacrum indicates a pressure ulcer, a common complication of immobility.
D. Difficulty hearing some types of sounds is unrelated to immobility.

A. Inform the provider that the PCA is not providing adequate pain relief. B. Ask the provider for a prescription to decrease the continuous rate. C. Instruct the client to push the button more frequently. D. Instruct the client's caregiver to push the PCA button when the client is resting.

Correct Answer is C

Explanation

A. The nurse should not inform the provider that the PCA is not providing adequate pain relief, as this is not true based on the client's pain rating of 2 out of 10.
B. The nurse should not ask the provider for a prescription to decrease the continuous rate, as this may compromise the client's pain relief and comfort.
C. The client should be encouraged to use the PCA pump before the pain becomes severe, as this will provide better pain control and reduce the risk of side effects.
D. Instructing the caregiver to push the button without the client's request may lead to overmedication and potential respiratory depression.

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

Correct Answer is C

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?

Correct Answer is C

Explanation

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

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?

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss?

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

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?

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?