While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Stage II pressure ulcer

Stage IV pressure ulcer

Stage I pressure ulcer

Stage III pressure ulcer

Answer and Explanation

The Correct Answer is A

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

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Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

If a visitor in the dining room at the hospital has a forceful cough, the nurse should first allow the visitor to continue coughing. Coughing is a natural reﬂex that helps clear the airway of foreign objects or mucus. The nurse should also assess the eﬀectiveness of the cough. If the cough is weak or ineﬀective, further intervention may be necessary.

Starting cardiopulmonary resuscitation (CPR) or performing the Heimlich maneuver would only be appropriate if the visitor is choking and unable to breathe. Assisting the client to a sitting position on the ﬂoor may not be necessary and could potentially cause harm.

A. To determine the need for medications B. To evaluate ﬂuid volume status C. To evaluate the glomerular filtration rate D. To determine the amount of retained urine after voiding. E. To determine the extent of renal failure

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

Explanation

A test to determine the amount of residual urine is used to measure the amount of urine that remains in the bladder after voiding. This assessment can be used for several reasons, including to determine the need for medications that can help improve bladder emptying and to evaluate the amount of retained urine after voiding. Retained urine can increase the risk of urinary tract infections and other complications. This test is not typically used to evaluate ﬂuid volume status, glomerular filtration rate, or the extent of renal failure.

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While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor? Select all that apply:

Correct Answer is ["C","D"]

Explanation

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Select all that apply.

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

Explanation

An unlicensed assistant (UAP) has previously performed client transfers safely (bed to chair) on many occasions. It would be inappropriate to delegate this unsupervised task to the UAP under which condition?

A nurse is conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me an antibiotic." What would be the most appropriate response by the nurse?

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

Which one of the following roles of the home health care nurse illustrates the role of coordinator of services?

A nurse is conducting an assessment on a client diagnosed with narcolepsy. The nurse should anticipate which of the following findings? Select all that apply.