A nurse is preparing to administer levothyroxine 100 mcg orally to a patient with hypothyroidism. The available levothyroxine is in 50 mcg tablets.
How many tablets should the nurse administer?

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

Choice A rationale
Checking that the client’s restraints are secured with a half-bow knot is a good practice. This type of knot is secure but can be easily untied, which is important for quick removal of the restraints if necessary.
Choice B rationale
Requesting that the provider prescribe the restraints as PRN is not a good practice. Restraints should only be used as a last resort and must be ordered by a healthcare provider. The order must specify the reason for the restraints and the duration of use.
Choice C rationale
Ensuring that the client’s wrists are padded is a good practice. Padding helps to prevent skin breakdown and nerve damage.
Choice D rationale
Loosening the restraints once every 4 hours is not a good practice. Restraints should be removed or loosened every 2 hours to allow for skin care and assessment, range of motion exercises, and to check for signs of injury.
Choice E rationale

Documenting client care every 15 minutes is a good practice. This includes documenting the client’s behavior, the type and location of restraints, the frequency of care (at least every 2 hours), and the client’s response to the restraints.