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 A

Explanation

Choice A rationale
Cranberry juice is an acceptable component of a clear liquid diet. Clear liquid diets are often prescribed postoperatively as they are easy to digest and leave no residue in the digestive tract.
Choice B rationale
Lemon sherbet is not part of a clear liquid diet. It is considered part of a full liquid diet, which is more substantial and includes foods that are liquid at room temperature.
Choice C rationale

Carrot juice is not typically included in a clear liquid diet. It may contain pulp and is not clear, which is a requirement of a clear liquid diet.
Choice D rationale
Plain yogurt is not part of a clear liquid diet. It is considered a solid food and is therefore not included.

A. Assist the guest to the floor and begin mouth-to-mouth resuscitation. B. Perform the Heimlich maneuver on the guest. C. Observe the guest before taking further action. D. Slap the guest on the back several times.

Correct Answer is B

Explanation

Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale

The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.

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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 caring for a postoperative patient following abdominal surgery. The surgeon has prescribed a clear liquid diet.Which of the following items should the nurse include on the patient’s lunch tray?

Correct Answer is A

Explanation

A nurse is at a social event when another guest suddenly coughs weakly once, grasps her throat with her hands, and is unable to speak. What action should the nurse take?

Correct Answer is B

Explanation

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