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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale
Assisting the guest to the floor and beginning mouth-to-mouth resuscitation is not the appropriate initial response. The guest’s symptoms indicate choking, and the Heimlich maneuver is the recommended first aid response.
Choice B rationale

The Heimlich maneuver is the correct response when someone is choking. The guest’s symptoms of a weak cough, inability to speak, and grasping the throat are classic signs of choking.
Choice C rationale
Observing the guest before taking further action is not appropriate in this situation. Immediate action is required to clear the guest’s airway.
Choice D rationale
Slapping the guest on the back is not the recommended response for choking in adults. It can potentially cause the object to become more deeply lodged in the throat.

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

Correct Answer is D

Explanation

Choice A rationale
Applying the pulse oximeter probe to the toe might not provide an accurate reading if the client has poor peripheral circulation. Additionally, thickened toenails can interfere with the reading.
Choice B rationale

Edema in the hands can affect the accuracy of a pulse oximeter reading. The probe might not fit properly or provide a reliable reading if the finger is swollen.
Choice C rationale
Applying the pulse oximeter probe to a skin fold is not recommended. The probe needs to be placed on a relatively flat, thin area of skin to accurately measure oxygen saturation.
Choice D rationale
The earlobe is a suitable alternative site for pulse oximetry if the fingers and toes are not viable options. The earlobe is typically less affected by peripheral vasoconstriction, which can occur with hypothermia, certain medications, and certain diseases. Therefore, Choice D is the correct answer.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is at a social event when another guest suddenly coughs weakly once, grasps her throat with her hands, and is unable to speak. What action should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to measure a client’s oxygen saturation and notes edema of the client’s hands and thickened toenails. Where should the nurse apply the pulse oximeter probe?

Correct Answer is D

Explanation

A nurse is caring for a postoperative patient following abdominal surgery. The surgeon has prescribed a clear liquid diet.Which of the following items should the nurse include on the patient’s lunch tray?

A nurse is caring for a client who requires a clear liquid diet. Which food is acceptable for the client to consume?

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?

A client is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

A nurse is caring for a client who is confused and has been placed in wrist restraints. Which of the following actions should the nurse take while caring for this client? (Select all that apply.)

Upon auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. What action should the nurse take?

A nurse is assessing an elderly patient receiving palliative care who exhibits Cheyne-Stokes respirations. Which of the following characteristics should the nurse identify as indicative of this respiratory pattern?

A nurse is performing chest physiotherapy on a client with a respiratory infection. Which technique should the nurse use to increase the velocity and turbulence of the client’s exhaled air?