A nurse is caring for a school-age child with respiratory failure due to pneumonia. Which position should the nurse encourage to allow for maximal lung expansion?

Prone

Supine

Side-lying

Upright

Answer and Explanation

The Correct Answer is D

Choice A rationale
The prone position, which involves lying flat on the stomach, is not typically recommended for a child with respiratory failure due to pneumonia. While prone positioning can be beneficial in

certain cases of severe acute respiratory distress syndrome, it does not generally allow for maximal lung expansion.
Choice B rationale
The supine position, which involves lying flat on the back, is not typically recommended for a child with respiratory failure due to pneumonia. This position can make it more difficult for the lungs to expand fully, potentially worsening respiratory distress.
Choice C rationale
The side-lying position is not typically recommended for a child with respiratory failure due to pneumonia. While this position can be comfortable for resting, it does not generally allow for maximal lung expansion.
Choice D rationale
The upright position is typically recommended for a child with respiratory failure due to pneumonia. Sitting upright can help to maximize lung expansion and improve oxygenation.

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Correct Answer is B

Explanation

Choice A rationale

Full-thickness tissue loss extending to underlying support structures such as muscle, tendon, or bone is characteristic of a stage 4 pressure ulcer, not a stage 312.
Choice B rationale
A stage 3 pressure ulcer involves full-thickness skin loss and may appear as a deep crater. There may be damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This description matches the statement in Choice B, making it the correct answer.
Choice C rationale
A shallow, ruptured or intact skin blister without slough is more indicative of a stage 2 pressure ulcer. In a stage 2 pressure ulcer, there is partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
Choice D rationale
Unbroken skin with un-blancheable erythema is characteristic of a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin is not broken, but it has redness that does not lighten (or blanch) when you press on it.

A. “I should have my son change the batteries in my smoke detectors each year.”. B. “I should use my walker carefully when going upstairs.”. C. “I should leave a night light on when I go to bed at night.”. D. “I should have grab bars installed in my bathroom.”. E. “I should have grab bars installed in my bathroom.”.

Correct Answer is B

Explanation

Choice A rationale
It is a good practice to change the batteries in smoke detectors annually to ensure they are working properly. This statement does not indicate a need for further instruction.
Choice B rationale
Using a walker when going upstairs can be dangerous due to the risk of falls. It is recommended that individuals use handrails or assistance when navigating stairs, not a walker. This statement indicates that the client needs further instruction.
Choice C rationale
Leaving a night light on can help prevent falls by providing visibility during the night. This statement does not indicate a need for further instruction.
Choice D rationale

Installing grab bars in the bathroom, especially near the toilet and in the shower, can provide support and prevent falls. This statement does not indicate a need for further instruction.

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A nurse is caring for a school-age child with respiratory failure due to pneumonia. Which position should the nurse encourage to allow for maximal lung expansion?

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Naxlex Comprehensive Predictor Exams

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which statement should the nurse use to describe a stage 3 pressure ulcer?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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