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 D

Explanation

A. While some clients with chronic pain may develop coping mechanisms, this does not mean that measures for relief are unnecessary. Pain management is still crucial for maintaining quality of life.
B. Opioid-based analgesics can be effective for some individuals with chronic pain, but their effectiveness can vary and they may not always be the best option due to potential side effects and the risk of dependence.
C. Chronic pain can be challenging to assess, but the perception and expression of pain are subjective and can vary greatly among individuals. Constant complaints of pain do not necessarily mean the pain intensity is difficult to assess; rather, it indicates the need for thorough pain evaluation.
D. Chronic pain often does not trigger the same physiological responses as acute pain. Therefore, vital signs such as heart rate, blood pressure, and pulse rate may remain normal even while the client is experiencing pain. This can make it more challenging to assess the presence and intensity of pain solely based on these parameters.

A. Lean patient against the bedside table. B. Splint the abdomen with a pillow. C. Support the patient's back. D. Offer an antitussive.

Correct Answer is B

Explanation

A. Leaning against a bedside table does not provide adequate support or comfort for coughing.
B. Splinting the abdomen with a pillow supports the incision site and reduces pain, making it easier for the patient to cough effectively.
C. Supporting the patient's back is helpful but not as effective as abdominal splinting for reducing pain during coughing.
D. Offering an antitussive is not appropriate as it suppresses coughing, which is needed to clear secretions postoperatively.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

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

Correct Answer is B

Explanation

What is the preferred IM injection site for a 1-year-old?

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

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?

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

Which fluid or product to be infused requires a central venous access rather than a peripheral access?

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

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?

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption?