When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a
dropdown
pressure ulcer.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B"}

Choice A rationale: Stage I pressure ulcers involve intact skin with non-blanchable redness, and there is no mention of intact skin in the scenario.

Choice B rationale: Stage II pressure ulcers involve partial thickness skin loss, typically presenting as an abrasion, blister, or shallow crater, which aligns with the description provided.

Choice C rationale: Stage III pressure ulcers involve full-thickness skin loss with damage to or necrosis of subcutaneous tissue but do not match the described scenario.

Choice D rationale: Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, which does not align with the description of partial thickness skin loss in the scenario.

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Correct Answer is C

Explanation

Choice A rationale: Stimulating deeper inhalations is a secondary benefit of CPT, but the primary purpose is to loosen secretions in congested areas.

Choice B rationale: Improving ciliary movement in the bronchioles is a secondary benefit of CPT, but the primary purpose is to loosen secretions.

Choice C rationale: Loosening secretions in congested areas is the primary purpose of CPT for clients with pneumonia.

Choice D rationale: Propelling oxygen along the respiratory tract is not the primary purpose of CPT but may be a secondary benefit.

A. gluteal maximus B. deltoid C. ventral gluteal D. vastus lateralis

Correct Answer is D

Explanation

Choice A rationale: The gluteal maximus is not a recommended site for intramuscular injections in infants due to the risk of injury to the sciatic nerve.

Choice B rationale: The deltoid muscle is a suitable site for older children and adults but may not be well-developed in infants.

Choice C rationale: The ventral gluteal site is not typically recommended for infants due to the potential risk of injury to the sciatic nerve.

Choice D rationale: The vastus lateralis muscle is the preferred injection site for intramuscular injections in infants.

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When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a dropdown pressure ulcer.

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Naxlex Comprehensive Predictor Exams

Chest physiotherapy (CPT) is ordered for a client with pneumonia. The nurse knows that the primary purpose of CPT for this client is to:

Correct Answer is C

Explanation

The nurse is administering an intramuscular injection to a 9 month old infant. What is the preferred injection site?

Correct Answer is D

Explanation

A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

A client is admitted to the hospital with a diagnosis of R/O appendicitis. Which abbreviation would describe the location of a client's appendix?

The nurse recognizes that the most appropriate reason to suction a client is that:

The nurse knows that teaching about the use of the spirometer incentive is effective when the client seals the lips around the mouthpiece and:

The nurse misreads the medication Kardex and administers twice the amount of antihypertensive medication that was ordered for the client. When she realizes the mistake, her first action should be to:

A nurse is caring for a client who has a diagnosis of alcohol withdrawal. Which serum laboratory value validates the client's admitting diagnosis? A serum:

The nurse is assessing a client who exhibits positive Trousseau's and Chvostek's signs. What laboratory value would validate these clinical findings? A serum:

The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues, which action should the nurse take?

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a
dropdown
pressure ulcer.