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 B
Explanation
Choice A rationale
Using a humidifier beside the bed at night may not necessarily decrease the number of apneic episodes in a client with obstructive sleep apnea. While a humidifier can help moisten the airways and may provide some relief from symptoms such as dry mouth or throat, it does not address the underlying issue of airway obstruction.
Choice B rationale
Losing weight can indeed help decrease the number of apneic episodes in a client with obstructive sleep apnea. Obesity is a major risk factor for sleep apnea, as excess fat tissue can thicken the wall of the windpipe, making it narrower and making it harder to keep open.
Therefore, losing weight can help reduce this fat and widen the airway, leading to fewer apneic episodes.
Choice C rationale
Taking a sleeping pill at night may actually worsen obstructive sleep apnea. While it might help the client fall asleep, it can also relax the muscles of the throat, which can make the airway more likely to collapse during sleep, leading to more apneic episodes.
Choice D rationale
Drinking a glass of red wine before bedtime is not recommended for a client with obstructive sleep apnea. Alcohol can relax the muscles in the throat and can disrupt the normal sleep cycle, both of which can lead to more apneic episodes.
Correct Answer is D
Explanation
Choice A rationale
While antibiotics are used to treat bacterial infections, crackles in the lungs can be a sign of various conditions, not just bacterial infections. Therefore, administering antibiotics is not the appropriate action based solely on the finding of crackles.
Choice B rationale
Limiting fluid intake can be beneficial for clients with certain conditions such as heart failure, but it is not the appropriate action based solely on the finding of crackles.
Choice C rationale
Initiating bedrest in semi-Fowler’s position can help improve lung expansion and ease breathing in clients with certain respiratory conditions. However, it is not the appropriate action based solely on the finding of crackles.
Choice D rationale
Crackles can sometimes be cleared by deep breathing and coughing. Repeating the auscultation after asking the client to breathe deeply and cough can help the nurse determine if the crackles are transient (cleared by coughing) or persistent.
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