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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Correct Answer is A

Explanation

A. This response emphasizes the importance of the patient controlling their own pain management. PCA pumps are designed to allow the patient to self-administer pain medication as needed, ensuring they receive the appropriate dose based on their pain levels.
B. This response is inappropriate because it undermines the purpose of a PCA pump, which is to allow the patient to control their own pain relief.
C. While the partner's intention is to help, this response does not address the potential risk of over-sedation and respiratory depression when someone other than the patient administers the medication.
D. This response questions the partner's actions but does not provide clear guidance on the proper use of the PCA pump.

A. Cover the bowel with a sterile saline dressing. B. Raise the patient up to a high Fowler's position. C. Call the RN. D. Turn the patient to the side of the evisceration.

Correct Answer is A

Explanation

A. Covering the bowel with a sterile saline dressing helps keep the bowel moist and prevents infection.
B. Raising the patient to a high Fowler's position can increase abdominal pressure and worsen the evisceration.
C. Calling the RN is important, but the immediate priority is to protect the protruding bowel.
D. Turning the patient to the side is not appropriate and does not address the immediate need to protect the bowel.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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

Correct Answer is A

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

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?

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

What technique will the nurse implement to assist the postoperative patient to cough?

A client with an aortic valve replacement is taking a daily dose of warfarin to prevent clot formation. The client states that he is also taking ginkgo biloba to Improve his memory and concentration. What would be the nurse's best response?

In providing care to a client with chronic pain, which of the following characteristics or client responses should the nurse expect?

A nurse is caring for a client who has severe rheumatoid arthritis in her hands and is unable to feed herself. For which of the following health care team members should the nurse request a referral from the provider?

A behavior that the nurse would expect in a young woman with bulimia includes