A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

Stage I Pressure Ulcer

Stage II Pressure Ulcer

Stage IV Pressure Ulcer

Stage III Pressure Ulcer

Answer and Explanation

The Correct Answer is B

Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.

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Correct Answer is D

Explanation

Choice A rationale: Lung sounds and chest x-ray are not directly relevant to assessing suspected food poisoning.
Choice B rationale: Routine urinalysis is not directly relevant to assessing suspected food poisoning.
Choice C rationale: Lung sounds and sputum sample are not directly relevant to assessing suspected food poisoning.
Choice D rationale: Bowel sounds and stool sample are relevant to assessing gastrointestinal symptoms associated with food poisoning.

A. purulent B. serous C. sanguineous D. serosanguineous

Correct Answer is D

Explanation

Choice A rationale: Purulent drainage is thick and opaque, often indicating infection.
Choice B rationale: Serous drainage is thin and watery, typically clear or slightly yellow.
Choice C rationale: Sanguineous drainage is bright red and indicates fresh bleeding.
Choice D rationale: Serosanguineous drainage is thin and pale pink-yellow, representing a mixture of serous and sanguineous components.

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A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?

Correct Answer is D

Explanation

A nurse caring for a postoperative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as:

Correct Answer is D

Explanation

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