The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?
Stage I Pressure Ulcer
Stage III Pressure Ulcer
Healing Stage III Pressure Ulcer
Healing Stage II Pressure Ulcer
The Correct Answer is C
A. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification.
B. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition.
C. Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes "healing" to show improvement.
D. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "If I develop atelectasis, I will need a chest tube to drain excess fluid." Atelectasis is alveolar collapse, not fluid accumulation. Chest tubes are used for pneumothorax or pleural effusion, not for atelectasis.
B. "Hyperventilation will open up my alveoli, preventing atelectasis." Hyperventilation can cause respiratory alkalosis but does not effectively re-expand alveoli. Incentive spirometry and deep breathing are more effective.
C. "Atelectasis affects only those with chronic conditions such as emphysema." Atelectasis can affect anyone, especially postoperatively due to shallow breathing and reduced lung expansion. It is not exclusive to chronic conditions.
D. "It is important to do breathing exercises every hour to prevent atelectasis." Frequent deep breathing exercises, coughing, and incentive spirometry are essential for preventing atelectasis, especially after surgery.
Correct Answer is C
Explanation
A. 4, 3, 2, 1 (Pulmonic → Tricuspid → Aortic → Mitral): This sequence incorrectly places the pulmonic valve first instead of the tricuspid.
B. 1, 3, 2, 4 (Mitral → Tricuspid → Aortic → Pulmonic): This sequence incorrectly starts with the mitral valve (left side of the heart), instead of the tricuspid (right side of the heart).
C. 3, 4, 1, 2 (Tricuspid → Pulmonic → Mitral → Aortic): Blood flow through heart valves follows this order:
- Tricuspid Valve (Right atrium → Right ventricle)
- Pulmonic Valve (Right ventricle → Pulmonary artery → Lungs)
- Mitral Valve (Left atrium → Left ventricle)
- Aortic Valve (Left ventricle → Aorta → Body)
D. 2, 4, 1, 3 (Aortic → Pulmonic → Mitral → Tricuspid): This sequence incorrectly places the aortic valve first, which is incorrect for blood flow through the heart.
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