Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

There is slough on part of the wound area.

There appears to be persistent reddening of the skin.

There is full-thickness skin loss with a crater.

There is a fluid-filled area under the skin.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

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Correct Answer is C

Explanation

Step 1 is to calculate the amount of amoxicillin in milliliters. Step 2: We know that 250 mg of amoxicillin is in 5 mL.
Step 3: We need to find out how many mL contain 350 mg of amoxicillin. Step 4: Set up a proportion: 250 mg/5 mL = 350 mg/x mL.
Step 5: Cross-multiply and solve for x: 250x = 1750. Step 6: Divide both sides by 250: x = 7 mL2.

A. Instruct the client to use a pursed-lip breathing technique. B. Increase the oxygen flow to 3L/min. C. Have the client cough and expectorate secretions. D. Evaluate the client’s respiratory status.

Correct Answer is D

Explanation

Choice A rationale
Pursed-lip breathing can help improve oxygenation and reduce shortness of breath in clients with COPD. However, it is not the priority action when a client reports difficulty breathing.
Choice B rationale
Increasing the oxygen flow rate without a physician’s order can lead to oxygen toxicity or suppress the respiratory drive in clients with COPD. Therefore, this is not the priority action.
Choice C rationale
Coughing and expectorating secretions can help clear the airways, but it is not the priority action when a client reports difficulty breathing.

Choice D rationale
Evaluating the client’s respiratory status is the priority action. The nurse should assess the client’s breath sounds, respiratory rate, use of accessory muscles, and oxygen saturation to determine the severity of the client’s difficulty breathing and guide further interventions.

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Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amoxicillin 350 mg PO. The available amoxicillin is 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

Correct Answer is C

Explanation

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.What is the nurse’s priority action?

Correct Answer is D

Explanation

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