Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

There appears to be persistent reddening of the skin.

There is a fluid-filled area under the skin.

There is full-thickness skin loss with a crater.

There is slough on part of the wound area.

Answer and Explanation

The Correct Answer is C

A.   This description is more indicative of a stage 1 pressure ulcer, where the skin is intact but shows non- blanchable redness. Stage 1 ulcers do not involve skin loss.
B.   This description might indicate a stage 2 pressure ulcer, where there is partial-thickness skin loss involving the epidermis and/or dermis. Stage 2 ulcers are characterized by shallow open ulcers with a red- pink wound bed, without slough.
C.   This description accurately defines a stage 3 pressure ulcer. Stage 3 ulcers involve full-thickness skin loss where adipose (fat) tissue may be visible, but deeper structures such as muscle, tendon, and bone are not exposed.
D.   Slough refers to yellow, tan, gray, green, or brown necrotic tissue in the wound bed that must be removed to facilitate wound healing. Slough can be present in both stage 3 and stage 4 pressure ulcers, where stage 4 involves full-thickness skin loss with exposure of muscle, bone, or supporting structures.

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Correct Answer is A

Explanation

A. Bananas are a good source of potassium. They contain approximately 422 mg of potassium per medium-sized banana. Including bananas in the diet can help replenish potassium levels in clients who are at risk of hypokalemia due to medications like furosemide.
B. Cheddar cheese is not a significant source of potassium. It contains only trace amounts of potassium. Therefore, it would not be beneficial for increasing potassium levels.
C. White rice is very low in potassium. It does not contribute significantly to potassium intake. Therefore, it would not be helpful for addressing hypokalemia.
D. Cabbage is also low in potassium. While it has some nutritional value, it does not provide a significant amount of potassium compared to other foods.

A. "Wear a mask when entering the client's room." B. "Gloves are not necessary if you wash your hands well." C. "Place a mask on the client when you check her vital signs." D. "Wear a gown whenever you come in close contact with the client."

Correct Answer is A

Explanation

A. Wearing a mask helps prevent the spread of respiratory droplets that may contain infectious pathogens, such as those causing pneumonia. It protects both the client from potential pathogens carried by the AP and the AP from potential exposure to the client's respiratory secretions.

B. Gloves should be worn when there is a risk of contact with the client's body fluids, including respiratory secretions, to prevent transmission of infectious agents. Hand hygiene (washing hands well) is important but does not replace the need for gloves in situations where there is a risk of exposure to bodily fluids.
C. Placing a mask on the client would not typically be required unless the client is coughing excessively and the mask is intended to contain respiratory droplets. However, the focus of precautions should primarily be on protecting the AP.
D. Wearing a gown may be necessary if there is a risk of contamination with respiratory secretions or if the AP anticipates contact with the client's body fluids. However, it is not specifically required for routine vital sign measurement unless there is visible contamination or extensive contact with the client's secretions.

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Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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