A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

Stage I Pressure ulcer.

Stage II Pressure ulcer.

Stage IV Pressure ulcer.

Stage II Pressure ulcer.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.

Choice B rationale:

Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.

Choice C rationale:

Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.

Choice D rationale:

Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.

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Correct Answer is C

Explanation

A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

A. Toe. B. Earlobe. C. Skin fold. D. Finger.

Correct Answer is B

Explanation

Choice A rationale:

Applying the pulse oximeter probe to the toe is not the most appropriate location. While toe measurements can be used, the fingers are more commonly used due to their accessibility and accuracy. Edema in the hands could affect the accuracy of readings.

Choice B rationale:

The nurse should apply the pulse oximeter probe to the earlobe. This choice is correct because the earlobe is a well-vascularized and easily accessible area that provides accurate oxygen saturation measurements. Thickened toenails and edema of the hands might compromise readings in those locations.

Choice C rationale:

Applying the pulse oximeter probe to a skin fold is not a recommended site for oxygen saturation measurement. While there are various sites where pulse oximeters can be applied, the earlobe and finger are more suitable due to their consistent blood flow and accessibility.

Choice D rationale:

While applying the pulse oximeter probe to the finger is a common and acceptable practice, in this scenario, edema of the hands could affect the accuracy of the readings. The earlobe is a better choice as it is less likely to be affected by edema and can provide accurate readings.

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A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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