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. This is a crucial step to prevent aspiration (the inhalation of oral contents into the lungs). Turning the client on their side helps to facilitate drainage and prevents oral fluids and debris from entering the airway during oral care.
B. Using a stiff toothbrush can be harmful to the gums and oral tissues, especially for clients who are unresponsive and may not be able to indicate discomfort. A soft-bristled toothbrush or moistened gauze is recommended for cleaning the teeth and gums to prevent injury and maintain oral hygiene effectively.
C. Applying petroleum jelly or a similar barrier ointment helps to moisturize and protect the lips from dryness and cracking, which can be common in clients who are unresponsive and may not be able to moisten their lips independently.
D. Using the thumb and index finger to keep the client's mouth open is gentle and effective. This technique allows the nurse to visualize and clean the oral cavity adequately without causing discomfort or injury to the client.

Correct Answer is ["93.75"]

Explanation

Infusion rate (mL/hr)= Total volume (mL)/Total time (hr) 750 mL divided by 8 hours equals 93.75 mL/hr
Therefore, the nurse should set the IV pump at 94Ml/HR

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NaCl) 750 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["93.75"]

Explanation

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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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