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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Cost and source of supply for the oxygen. B. Safety measures necessary to prevent a fire. C. Having the healthcare provider's phone number readily available. D. Need to provide good skin care.

Correct Answer is B

Explanation

The correct answer is choice B, safety measures necessary to prevent a fire. When teaching a home care client and their family about using prescribed oxygen, safety measures are critical. Oxygen supports combustion, so it is important to follow safety measures to prevent a fire. These safety measures include avoiding smoking, using electric razors instead of a blade, and avoiding flammable products such as oils, aerosol sprays, and alcohol-based hand sanitizers near the oxygen source. The oxygen should be kept away from heat sources and the tubing should be free from kinks or damage. The healthcare provider's phone number should also be readily available in case of any questions or emergencies.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor in regard to safety that must be included in teaching?

Correct Answer is B

Explanation

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is dark red in color. The nurse documents the drainage as which of the following?

For a client at a high risk of aspiration, the nurse anticipates that there will be goals and interventions (taking action) related to safety observations during:

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.

Which of the following is the best example of a measurable client goal? The client will:

Which of the following is the best example of a measurable client goal? The clientwill:

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. Which of the following are the three energy-supplying nutrients?

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the denial stage?