A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?

Full thickness skin loss with visible bone.

Intact skin with localized erythema.

Partial-thickness skin loss with red tissue.

Full thickness skin loss with visible adipose tissue.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

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Correct Answer is D

Explanation

Choice A rationale

Measuring the bladder before the patient voids would not provide an accurate measurement of postvoid residual, which is the amount of urine left in the bladder after voiding.

Choice B rationale

The position of the head of the bed does not directly impact the measurement of postvoid residual. However, the patient should be in a comfortable position during the procedure.

Choice C rationale

Similar to Choice B, the position of the head of the bed does not directly impact the measurement of postvoid residual.

Choice D rationale

Measuring the bladder within 15 minutes after the patient voids allows for an accurate measurement of postvoid residual, which can help assess bladder function.

A. Observe the patient’s respiratory status. B. Elevate the head of the patient’s bed 30° to 45°. C. Monitor intake and output every 8 hours. D. Check residual volume every 4 to 6 hours.

Correct Answer is B

Explanation

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.

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A nurse is assessing a client with a skin condition. Which of the following describes the client’s condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take?

Correct Answer is D

Explanation

A nurse is developing a care plan for a patient with a decreased level of consciousness who is receiving continuous enteral feedings through a gastrostomy tube due to an inability to swallow.What should be the nurse’s priority action?

Correct Answer is B

Explanation

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