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?
Full-thickness tissue loss extending to underlying support structures
A deep crater without visible bone, tendon, or muscle
A shallow, ruptured or intact skin blister without slough
Unbroken skin with un-blancheable erythema
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale
Increasing the client’s oral fluid intake is not the immediate action the nurse should take. While hydration is important, it does not directly address the client’s low oxygen saturation.
Choice B rationale
Initiating humidification therapy can help to thin secretions and improve oxygenation, but it is not the immediate action the nurse should take.
Choice C rationale
Raising the head of the bed is the first action the nurse should take. This position can help to improve lung expansion and oxygenation.
Choice D rationale
Encouraging the client to cough and deep breath can help to clear secretions and improve oxygenation, but it is not the immediate action the nurse should take.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.