A nurse begins her shift and is completing her first turn of the night. While turning, she also assesses her patient's skin. When she turns her patient she finds the following wound on her coccyx. How should she document the following wound? (The base of the wound is muscle, with some subcutaneous tissue)
Stage III Pressure Ulcer
Stage IV Pressure Ulcer
Stage II Pressure Ulcer
Unstageable Ulcer
The Correct Answer is B
Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale: Contractures are a common complication of immobility due to the shortening of muscles and connective tissues.
Choice B rationale: Diarrhea is not typically associated with complications of immobility.
Choice C rationale: Polyuria is not typically associated with complications of immobility.
Choice D rationale: Atelectasis, the collapse of lung tissue, can occur in immobile clients due to reduced lung expansion and ventilation.
Choice E rationale: Pressure ulcers are a significant risk in immobile clients due to prolonged pressure on specific areas of the body.
Correct Answer is A
Explanation
Choice A rationale: The statement "I need to void after sexual intercourse to flush microorganisms away from my urethra" is correct. Voiding after sexual intercourse can help prevent the ascent of microorganisms into the urethra and reduce the risk of urinary tract infections.
Choice B rationale: Wearing snug-fitting pants can contribute to a warm and moist environment, potentially increasing the risk of urinary tract infections rather than preventing them.
Choice C rationale: Wiping from the anus to the vagina after going to the bathroom can introduce microorganisms into the urethral area, increasing the risk of urinary tract infections.
Choice D rationale: Frequent bubble baths can disrupt the natural balance of microorganisms in the genital area and increase the risk of urinary tract infections.
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