The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Stage 1 pressure ulcer

Stage 4 pressure ulcer

Stage 2 pressure ulcer

Stage 3 pressure ulcer

Answer and Explanation

The Correct Answer is D

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

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Correct Answer is C

Explanation

A. Limiting activity can contribute to constipation, so the nurse should encourage regular physical activity to promote bowel function.

B. Drinking four to five glasses of water daily is insufficient; older adults typically need at least 6-8 glasses to help prevent constipation.

C. Increasing dietary intake of raw vegetables provides fiber, which is essential for promoting bowel regularity and preventing constipation. This recommendation aligns with dietary guidelines for improving gastrointestinal health.

D. Bearing down hard when defecating can lead to complications such as hemorrhoids or valsalva maneuvers, so clients should be taught to relax and allow for a natural bowel movement instead.

A. Application of antibiotic ointment to the arm of a client who has dermatitis B. Removal of the nasogastric tube of a client who has been receiving enteral feedings C. Monitoring vital signs of a client who had an appendectomy 12 hr ago D. Obtaining medical history information from a stable client who is being admitted

Correct Answer is C

Explanation

A. Application of antibiotic ointment involves assessment and clinical judgment, which should be performed by a licensed nurse rather than an AP.

B. The removal of a nasogastric tube is a nursing task that requires training and knowledge of potential complications, and it should not be assigned to an AP.

C. Monitoring vital signs of a client who had an appendectomy 12 hours ago can be safely delegated to an AP, as it is a basic task that does not require clinical judgment beyond standard procedures.

D. Obtaining medical history information from a stable client is a task that requires assessment skills and critical thinking, making it inappropriate to assign to an AP.

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The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?

Correct Answer is C

Explanation

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