A paraplegic patient is admitted to the hospital for intensive management of an open, infected pressure ulcer on the left buttock at the prominence of the ischial tuberosity. The initial assessment of the patient's pressure ulcer indicates that it is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The wound is a full thickness ulcer, has some slough present and extends through the dermis into the subcutaneous tissue. No exposed muscle, tendons, ligaments, cartilage, or bones present. The nurse classifies the pressure ulcer as

Stage II

Stage I

Stage III

Stage IV

Answer and Explanation

The Correct Answer is C

A. Stage II pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
B. Stage I pressure ulcers are characterized by intact skin with non-blanchable redness.
C. Stage III pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
D. Stage IV pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Endotracheal intubation might be necessary in severe cases of respiratory depression, but it is not the first step in addressing opioid overdose.
B. Protamine sulfate is the antidote for heparin, not morphine.
C. Naloxone (Narcan) is an opioid antagonist that can rapidly reverse the effects of opioid overdose, including respiratory depression.
D. Administration of oxygen is supportive care but does not address the root cause of opioid overdose.

A. “It is never permissible to use herbal supplements with prescription medications." B. "Herbs are not classified as drugs in the United States, so there is no contraindication to using them." C. “I will refer you to an herbalist who can help you decide which medications you can take." D. "Herbs have pharmacologic effects on the body and can interact with some prescription medications."

Correct Answer is D

Explanation

A. It is not accurate to say it is never permissible; some herbal supplements may be safely used with certain medications under professional guidance.
B. Herbs can have pharmacologic effects and may interact with prescription medications, even if they are not classified as drugs in the U.S.
C. Referring to an herbalist is not the best immediate response; the nurse should first address potential interactions and safety concerns.
D. Herbs can indeed have pharmacologic effects and interact with prescription medications, potentially causing adverse effects or altering the effectiveness of the medications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse accidentally administers 15 mg of morphine IM to a client who had been given another dose of morphine 15 mg IM about 30 minutes earlier. What action should the nurse be prepared to take?

Correct Answer is C

Explanation

A client tells a nurse that she is considering using herbal supplements in addition to her prescription medications. What would be the nurse's best response?

Correct Answer is D

Explanation

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss?

A nurse is caring for a postoperative client who has an IV PCA delivering opioids. The client rates their pain as 2 on a scale of 0 to 10 and has not pressed the button to deliver a bolus dose in over 2 hr. Which of the following actions should the nurse take?

A nurse is caring for a client who has a large lower leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Which of the following are examples of low-risk complementary and alternative therapies that nurses can use with their clients?

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?