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 D

Explanation

Choice A rationale
The prone position, which involves lying flat on the stomach, is not typically recommended for a child with respiratory failure due to pneumonia. While prone positioning can be beneficial in

certain cases of severe acute respiratory distress syndrome, it does not generally allow for maximal lung expansion.
Choice B rationale
The supine position, which involves lying flat on the back, is not typically recommended for a child with respiratory failure due to pneumonia. This position can make it more difficult for the lungs to expand fully, potentially worsening respiratory distress.
Choice C rationale
The side-lying position is not typically recommended for a child with respiratory failure due to pneumonia. While this position can be comfortable for resting, it does not generally allow for maximal lung expansion.
Choice D rationale
The upright position is typically recommended for a child with respiratory failure due to pneumonia. Sitting upright can help to maximize lung expansion and improve oxygenation.

A. “I should have my son change the batteries in my smoke detectors each year.”. B. “I should use my walker carefully when going upstairs.”. C. “I should leave a night light on when I go to bed at night.”. D. “I should have grab bars installed in my bathroom.”. E. “I should have grab bars installed in my bathroom.”.

Correct Answer is B

Explanation

Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale

Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.

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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 school-age child with respiratory failure due to pneumonia. Which position should the nurse encourage to allow for maximal lung expansion?

Correct Answer is D

Explanation

A nurse is reinforcing home safety information with an older adult client. Which of the following statements indicates that the client needs further instruction?

Correct Answer is B

Explanation

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