The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?
The ulcer has thick dark eschar over the top
Exposed bone/tendon is visible
There is partial-thickness loss of dermis
The wound extends into the subcutaneous tissue.
The Correct Answer is B
B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.
A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.
C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.
D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Drug absorption refers to the process by which a drug moves from its site of administration into the bloodstream. Once absorbed into the bloodstream (systemic circulation), drugs can distribute to various tissues and exert their therapeutic effects.
A. Different routes of drug administration affect the rate and extent of absorption. Subcutaneous injections are generally absorbed more quickly than intramuscular injections due to differences in blood flow and tissue characteristics.
C. The effect of meals on drug absorption varies depending on the specific medication. Some drugs are absorbed faster on an empty stomach, while others may be absorbed better with food.
D. Mucous membranes, contrary to the statement, are relatively permeable to drugs, allowing for rapid absorption when medications are administered via buccal, sublingual, rectal, or vaginal routes.
Correct Answer is ["24"]
Explanation
For a client prescribed 2 grams of amoxicillin/clavulanic acid every 12 hours, and given that the medication is supplied in 500 mg capsules,
The client would need to take four capsules to meet the 2-gram requirement per dose. Since the medication is to be taken every 12 hours, this equates to two doses per day.
For a 3-day business trip, the client would need to take a total of 6 doses. Therefore, the client should take 24 capsules (4 capsules per dose multiplied by 6 doses) with them to ensure they have enough medication for the duration of their trip.
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