A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

stage I

stage II

stage III

stage IV

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. The description of full-thickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer indicates a pressure ulcer that is categorized as stage IV. In this stage, the ulcer is characterized by fullthickness tissue loss, exposing muscle, bone, or tendons. Stage I (choice A) pressure injuries involve non-blanchable erythema of intact skin. Stage II (choice B) pressure injuries involve partial-thickness skin loss, which can involve the epidermis, dermis, or both. Stage III (choice C) pressure injuries involve fullthickness tissue loss, but not bone, tendon, or muscle. Therefore, based on the description provided, the pressure ulcer is categorized as stage IV.

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Correct Answer is B

Explanation

The correct answer is choice B. When interviewing a newly admitted patient, the nurse can best exhibit cultural competence by asking open-ended questions that show an interest in and respect for the patient's cultural background. The question "What types of food do you eat for meals?" (choice B) is an open-ended question that allows the patient to provide information about their cultural food preferences and dietary needs. By asking this question, the nurse can gain insight into the patient's cultural background and develop a plan of care that is respectful of their cultural beliefs and practices.

In contrast, the questions "Do you think you will be able to eat the food we have here?" (choice A) and "Do you understand we can't prepare special meals?" (choice C) may be perceived as insensitive or dismissive of the patient's cultural background. These questions do not take into account the patient's cultural preferences and needs, and may make the patient feel marginalized or disrespected. The question "Why can't you just eat our food while you are here?" (choice D) is confrontational and may be perceived as judgmental or dismissive of the patient's needs. Therefore, the best question to exhibit cultural competence when interviewing a newly admitted patient is an open-ended question that shows an interest in and respect for the patient's cultural background, such as "What types of food do you eat for meals?" (choice B).

A. Pallor. B. Jaundice. C. C. Cyanosis. D. Erythema.

Correct Answer is C

Explanation

The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.

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A nurse assesses a patient's pressure injury and documents the following: fullthickness skin and tissue loss with exposed muscle, tendon, and bone in the ulcer. This pressure ulcer is categorized to be at which of the following stages?

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Naxlex Comprehensive Predictor Exams

A nurse is interviewing a newly admitted patient. What question would best exhibit cultural competence?

Correct Answer is B

Explanation

A nurse is performing a head to toe assessment on a client. Which of the following assessment findings would the nurse recognize as requiring an immediate action and would be the first priority when addressing a patient health problem?

Correct Answer is C

Explanation

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

When conducting a physical assessment of the extremities, which of the following assessments would be the most correct?

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?