A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

Unstageable Ulcer

Stage II Pressure Ulcer

Stage IV Pressure Ulcer

Stage III Pressure Ulcer

Answer and Explanation

The Correct Answer is A

Choice A rationale: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.

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Correct Answer is D

Explanation

Choice A rationale: Lung sounds and chest x-ray are not directly relevant to assessing suspected food poisoning.
Choice B rationale: Routine urinalysis is not directly relevant to assessing suspected food poisoning.
Choice C rationale: Lung sounds and sputum sample are not directly relevant to assessing suspected food poisoning.
Choice D rationale: Bowel sounds and stool sample are relevant to assessing gastrointestinal symptoms associated with food poisoning.

A. Encourage fluid intake B. Reduce fluid intake C. Alert the healthcare provider of possible infection D. No action is required

Correct Answer is A

Explanation

Choice A rationale: Dark yellow urine may indicate concentrated urine, and encouraging fluid intake helps dilute the urine, promoting kidney function and preventing dehydration.
Choice B rationale: Reducing fluid intake is not appropriate based solely on the color of the urine. It is essential to assess overall hydration status.
Choice C rationale: Dark yellow urine alone does not necessarily indicate infection. Other symptoms and laboratory tests would be needed for a diagnosis.
Choice D rationale: Taking no action is not appropriate when the color of urine suggests dehydration. Assessing and addressing hydration status are important.

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A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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