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 D
Explanation
Choice A rationale
The deltoid muscle is not typically used for injections in newborns. It is not as developed as the vastus lateralis and does not have as much muscle mass.
Choice B rationale
The ventrogluteal muscle is generally not used for injections in newborns. It is not as accessible or as well developed as the vastus lateralis.
Choice C rationale
The dorsogluteal muscle is not recommended for injections in newborns due to the risk of damaging the sciatic nerve.
Choice D rationale
The vastus lateralis muscle is the preferred site for intramuscular injections in newborns. It is the most developed muscle in this age group and is free of major nerves and blood vessels.
Correct Answer is B
Explanation
Choice A rationale
Withholding the medication until the prescribing provider is available could potentially put the patient at risk, especially if the medication is critical for the patient’s health and well-being.
Choice B rationale
Requesting to speak with the provider who is covering for the prescriber is the most appropriate action in this situation. This allows the nurse to clarify the prescription and ensure the safety of the patient.
Choice C rationale
Contacting the pharmacy to confirm that the dosage is safe to administer could be a part of the process, but it should not be the first step. The nurse should first contact a healthcare provider to discuss the prescription.
Choice D rationale
Informing the charge nurse and administering the usual dose of the medication without first consulting with a healthcare provider could potentially put the patient at risk.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.