The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

Stage IV

Stage II

Stage III

Unstageable

Answer and Explanation

The Correct Answer is D

D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable

A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.

B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.

C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.

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Correct Answer is ["B","C","D"]

Explanation

B. Temperature can significantly affect sleep quality. Ensuring the room is kept at a comfortable temperature (not too hot or cold) can promote better sleep. This intervention is appropriate.

C. Clean and dry bed linens contribute to comfort, which is essential for promoting sleep. This intervention is appropriate.

D. Discomfort can be a major barrier to sleep. Addressing any discomfort, such as pain, anxiety, or positioning issues, can help improve the client's ability to fall and stay asleep. This intervention is appropriate.

A. Offering chocolate, which contains caffeine, close to bedtime is not recommended as caffeine can interfere with sleep. Therefore, this option is not appropriate.

E. Moving the client closer to the nursing station may increase noise and disrupt sleep, especially if there are frequent activities or conversations near the nursing station. Therefore, this option is not typically recommended unless the client requires closer monitoring due to medical reasons.

Correct Answer is ["1700"]

Explanation

To calculate the time when a new IV bag will be needed, we can divide the total volume left in the bag by the infusion rate.

With 500 ml remaining and an infusion rate of 100 ml per hour, it will take 5 hours for the current bag to be depleted.

Since the report was given at 1200 (which is noon in military time), adding 5 hours brings us to 1700, or 5:00 PM.

Therefore, the nurse should expect to hang a new IV bag at 1700 hours in military time.

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The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is having difficulty sleeping in the hospital environment. How can the nurse intervene? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag? Report the time in military time.

Correct Answer is ["1700"]

Explanation

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