The nurse is to administer 10 mg/kg of acetaminophen to a patient who weighs 70 pounds (32 kg). The acetaminophen elixir is 160 mg per 5 mL. How many mL of medication will be given to the patient for each dose?

Choice A rationale:

Indurated describes tissue that is hardened and thickened, typically due to inflammation or fibrosis. While a decubitus ulcer with thick necrotic tissue may feel firm to the touch, induration does not accurately capture the extent of tissue damage and depth of the wound.

Indurated tissue often feels leathery or stiff, while necrotic tissue can be more varied in texture, ranging from dry and crusty to soft and sloughy.

Additionally, induration can occur in wounds that are not full-thickness ulcers, such as pressure injuries that have not yet progressed to the point of tissue loss.

Choice B rationale:

Fluctuant describes a fluid-filled cavity beneath the skin. While a decubitus ulcer with thick necrotic tissue may have some underlying fluid, it would not typically be described as fluctuant.

Fluctuance is more characteristic of abscesses or other fluid collections that have a distinct, palpable pocket of fluid.

The presence of thick necrotic tissue in a decubitus ulcer can obscure the presence of any underlying fluid, making it difficult to assess for fluctuance.

Choice D rationale:

Macerated describes skin that is softened and broken down due to prolonged exposure to moisture. While maceration can occur in the surrounding skin of a decubitus ulcer, it does not accurately describe the ulcer itself.

Maceration is typically seen in areas where skin folds rub together, such as the groin or armpits, and is often associated with incontinence or excessive sweating.

The presence of thick necrotic tissue in a decubitus ulcer indicates a more advanced stage of tissue damage that is not simply due to moisture exposure.

Choice C rationale:

Unstageable is the most accurate term to describe a decubitus ulcer with thick necrotic tissue because it indicates that the extent of tissue damage cannot be fully assessed.

Thick necrotic tissue obscures the base of the wound and the surrounding tissue, making it impossible to determine the depth of the ulcer or the extent of undermining.

This lack of visibility prevents accurate staging of the ulcer using the traditional pressure ulcer staging system, which categorizes ulcers based on their depth and extent of tissue involvement.

Therefore, unstageable is the most appropriate term to describe a decubitus ulcer with thick necrotic tissue.

The correct answer is E(None of the Above)

Rationale for E:

The options A, B, C, and D all describe actions or physiological measurements that do not directly indicate an allergic reaction.

Allergic reactions involve the immune system's response to a specific substance, whereas side effects are unintended reactions to a medication that are not caused by an immune response.

Key differences between allergic reactions and side effects:

Allergic reactions:

Typically occur rapidly after exposure to the allergen.

Can involve various body systems, including the skin (hives, itching, rash), respiratory system (wheezing, difficulty breathing, throat tightness), gastrointestinal system (nausea, vomiting, diarrhea), and cardiovascular system (low blood pressure, shock).

May be life-threatening in severe cases, such as anaphylaxis. Side effects:

Can occur at any time during medication use.

Usually more predictable and less severe than allergic reactions.

Often subside as the body adjusts to the medication or with dose adjustments. Important considerations for nurses:

Carefully assess patients for potential allergies before administering medications.

Monitor patients closely for any signs of allergic reactions or side effects after medication administration.

Promptly intervene if an allergic reaction is suspected, following established protocols and administering emergency medications as needed.

Document all observations and actions related to medication administration and patient responses.