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

Choice A rationale
Massaging the site after injection is not recommended. It can cause the insulin to be absorbed more quickly than intended, which could lead to hypoglycemia.
Choice B rationale
Using cold insulin for injection to minimize site pain is not accurate. Insulin should be at room temperature when injected. Cold insulin can make the injection more painful.
Choice C rationale
Rotating the injection site is important to prevent lipodystrophy, a condition that causes abnormal fat deposits at the injection site. It also helps to keep insulin levels consistent.
Choice D rationale
Insulin is not absorbed most rapidly when injected in the thigh. The abdomen is actually the site where insulin is absorbed most quickly.

A. “The client should first move the strong leg then the weak one.”. B. “When the client moves, he should move the cane forward first.”. C. “The client should hold the cane on the weak side of his body.”. D. “The grip should be level with the client’s waist.”. .

Correct Answer is B

Explanation

Choice A rationale

The statement “The client should first move the strong leg then the weak one” is not the best practice when using a cane. The client should move the cane and the weak leg forward at the same time, then move the strong leg.
Choice B rationale
The statement “When the client moves, he should move the cane forward first” is the correct practice. Moving the cane first provides stability and support for the next step.
Choice C rationale
The statement “The client should hold the cane on the weak side of his body” is not the correct practice. The cane should be held on the strong side of the body to provide support for the weak side.
Choice D rationale
The statement “The grip should be level with the client’s waist” is a good practice, but it’s not the best answer for this question. The grip of the cane should be at the level of the client’s wrist when the client’s arm is hanging down. This allows the client to maintain a slight bend in their elbow when holding the cane.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about insulin injections with a client who is newly diagnosed with type I diabetes mellitus. What information should the nurse include about site selection?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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