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 C

Explanation

The correct answer is choice C, Pulse amplitude. Pulse amplitude is a measure of the strength of the pulse and is rated on a 0-4 scale, with 0 indicating no pulse and 4 indicating a bounding pulse. A brisk pulse with a +2 rating suggests a normal pulse strength that is easily felt and is not weak or bounding. Pulse rhythm describes the regularity or irregularity of the pulse beats and is not related to pulse strength. Pulse deficit refers to the difference between the apical and radial pulse rates and is determined by auscultating the apical pulse while simultaneously palpating the radial pulse. Pulse arrhythmia refers to an irregular pulse rhythm.

A. Air pads wrap around your arms and are connected to a vacuum which improves blood flow. B. These are elastic stockings that apply pressure to the legs and increase the velocity of blood flow. C. SCDs are only worn during amputation to provide support and prevent pooling of blood in the legs. D. The device fills with air that applies intermittent or sequential pressure to the legs to enhance blood flow and venous return.

Correct Answer is D

Explanation

The correct answer is choice D. The nurse would explain to the patient that SCDs work by filling with air and applying intermittent or sequential pressure to the legs to enhance blood flow and venous return. This can help prevent blood clots, such as DVT, from forming in the legs. SCDs are often used for patients who are immobile, such as those who have undergone surgery or who are hospitalized for a medical condition. The device is comfortable to wear and can be adjusted to fit the patient's size and shape. The nurse would also explain the importance of wearing the device as prescribed, and how to properly use and care for it. By using SCDs as directed, the patient can significantly reduce their risk of developing a potentially life-threatening blood clot.

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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 assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

Correct Answer is C

Explanation

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

Correct Answer is D

Explanation

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