When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Perform hand hygiene.

Assess the condition of the visible wound bed.

Measure the width of the wound with a disposable ruler.

Insert a swab into the wound at 90 degrees.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Performing hand hygiene before any wound care procedure is essential to prevent infection and maintain aseptic technique.
Choice B rationale: Assessing the condition of the visible wound bed is an important step but not the first action. Hand hygiene should precede any assessment or intervention.
Choice C rationale: Measuring the width of the wound with a disposable ruler is part of the wound measurement process but should follow hand hygiene.
Choice D rationale: Inserting a swab into the wound at 90 degrees is not the first step. Hand hygiene and assessment should precede any invasive procedures.

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Correct Answer is A

Explanation

Choice A rationale: A purplish-colored stoma may indicate compromised blood supply and should be reported to the provider.
Choice B rationale: A shiny, moist stoma is a healthy characteristic of a colostomy. Choice C rationale: Stoma oozing red drainage is a normal finding after colostomy surgery.
Choice D rationale: "Budded" stoma is not a recognized term related to colostomy assessment.

A. Contractures B. Diarrhea C. Polyuria D. Atelectasis E. Pressure ulcers

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale: Contractures are a common complication of immobility due to the shortening of muscles and connective tissues.
Choice B rationale: Diarrhea is not typically associated with complications of immobility.
Choice C rationale: Polyuria is not typically associated with complications of immobility.
Choice D rationale: Atelectasis, the collapse of lung tissue, can occur in immobile clients due to reduced lung expansion and ventilation.
Choice E rationale: Pressure ulcers are a significant risk in immobile clients due to prolonged pressure on specific areas of the body.

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When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: