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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Correct Answer is C

Explanation

When communicating with a client who has difficulty hearing a conversation, it is important for the nurse to face the client during the conversation. This allows the client to see the nurse's mouth and facial expressions, which can help them better understand what is being said. Additionally, facing the client can help reduce background noise and improve the clarity of the nurse's speech.

A. Asymmetrical chest expansion B. Breath sounds equal bilaterally C. Bilateral symmetric vocal fremitus D. Chest symmetrical

Correct Answer is A

Explanation

During a lung assessment on a client suspected of having pneumonia, the nurse should report asymmetrical chest expansion to the physician immediately. Asymmetrical chest expansion can be a sign of a serious lung condition such as pneumonia. The other options (Breath sounds equal bilaterally, Bilateral symmetric vocal fremitus, and Chest symmetrical) are normal findings and do not need to be reported immediately.

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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

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

Correct Answer is C

Explanation

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

Correct Answer is A

Explanation

The nurse is oﬀering free occult blood screenings at a community health fair. Which level of practice is the nurse providing?

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

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