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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Hold her breath for at least 10 seconds. Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort.

B. Place her hands on the sides of her rib cage. While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding.

C. Exhale forcefully through the nose. Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.

D. Inhale slowly and evenly through her nose. The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively.

A. AV Node B. SA Node C. Purkinje Fibers D. Bundle of HIS

Correct Answer is B

Explanation

A. AV Node: The AV node is responsible for delaying electrical impulses before they pass to the ventricles, but it does not generate the P wave. It affects the PR interval rather than the P wave itself.

B. SA Node: The SA (sinoatrial) node initiates electrical impulses and is responsible for atrial depolarization, which produces the P wave on an ECG. This makes it the correct answer.

C. Purkinje Fibers: The Purkinje fibers play a role in ventricular contraction (QRS complex), not in the formation of the P wave.

D. Bundle of HIS: The Bundle of HIS transmits impulses to the ventricles and is involved in ventricular depolarization, not atrial activity. It is not responsible for the P wave.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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