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. Lean the client toward the wall. B. Assume a narrow base of support. C. Lower the client to the floor. D. Provide support by holding the client's arm

Correct Answer is C

Explanation

Choice A rationale: Leaning the client toward the wall may not provide sufficient support and could lead to a fall.
Choice B rationale: Assuming a narrow base of support does not provide adequate stability when a client is falling.
Choice C rationale: Lowering the client to the floor is a safety measure to prevent injury during a fall. It reduces the distance of the fall and minimizes the risk of injury.
Choice D rationale: Providing support by holding the client's arm may not be sufficient to prevent a fall. Lowering the client to the floor is a safer option.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?

Correct Answer is D

Explanation

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

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.)

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

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?

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

A client at a healthcare facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?