Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

Disposable measuring tape

Cotton-tipped applicator

Natural light

Sterile gloves

Answer and Explanation

The Correct Answer is C

A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.

B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.

C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.

D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.

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Correct Answer is C

Explanation

A. Assess the pedal pulses for a full minute. Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate.

B. Assess the apical pulse with a Doppler device. A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation.

C. Assess the apical pulse for a full minute. When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias.

D. Assess the pedal pulses with a Doppler device. Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.

A. "I will administer the medications 10 minutes apart.” B. "I will use both medications immediately after exercising.” C. "I will be sure to take the albuterol before taking the cromolyn." D. "If my breathing begins to feel tight, I will use the cromolyn immediately."

Correct Answer is C

Explanation

A. "I will administer the medications 10 minutes apart."Timing is important, but this option does not specify which medication should be taken first. The correct sequence is albuterol first, followed by cromolyn.

B. "I will use both medications immediately after exercising." Cromolyn is a mast cell stabilizer used for prevention, not acute symptoms. It should be taken 15-30 minutes before exercise to prevent exercise-induced bronchospasm, not after.

C. "I will be sure to take the albuterol before taking the cromolyn." Albuterol (a bronchodilator) should be taken first to open the airways, allowing better absorption of cromolyn (an anti-inflammatory medication).

D. "If my breathing begins to feel tight, I will use the cromolyn immediately." Cromolyn is not a rescue medication. Albuterol should be used for acute bronchospasm, while cromolyn is for long-term asthma control.

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Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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