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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Step 1 is to determine how many mL to administer. The client needs 300 mg of amoxicillin and the available medication is 250 mg/5 mL. So, the calculation is (300 mg ÷ 250 mg/mL) × 5 mL.
Step 2 is to perform the calculation. The result is 6 mL.
Correct Answer is B
Explanation
Step 1 is to determine how many tablets to administer. The client needs 650 mg of aspirin and each tablet contains 325 mg. So, the calculation is 650 mg ÷ 325 mg/tablet.
Step 2 is to perform the calculation. The result is 2 tablets.
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