Try Naxlex NCLEX-RN (Free-Trial)

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

A.

Stage II

B.

Stage I

C.

Stage III

D.

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.
 


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

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

A. Petroleum jelly can be applied, but it is not the priority action.
B. Using the thumb and index finger to keep the client's mouth open can be unsafe and uncomfortable.
C. A soft toothbrush should be used to prevent injury to the oral mucosa.
D. Turning the client on his side reduces the risk of aspiration during oral care.

Correct Answer is D

Explanation

A. Fresh-frozen plasma can be administered via peripheral access.
B. Dextrose 10% in water can typically be administered via peripheral access.
C. 0.9% sodium chloride (normal saline) can be administered via peripheral access.
D. Parenteral nutrition formula, particularly if it is hyperosmolar, often requires central venous access due to the high concentration of glucose and nutrients, which can irritate peripheral veins and require a more stable infusion rate.

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

Register