Try Naxlex NCLEX-RN (Free-Trial)

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.
The nurse examines the sacral ulcer and determines it is a Stage II ulcer.
Which of these findings is characteristic of a Stage II pressure ulcer?

Patches of eschar cover parts of the wound.

Partial thickness skin erosion is observed with a loss of dermis and epidermis.

Ulcer extends into the subcutaneous tissue.

Intact skin appears red but not broken.

Open blister areas have a red-pink wound bed.

Localized redness in light skin will blanch with fingertip pressure.

Answer and Explanation

Correct Answer : B,E

Choice A rationale

Patches of eschar covering parts of the wound are characteristic of more advanced pressure ulcers, such as Stage III or IV, where necrotic tissue is present. Eschar is a dark, thick, leathery scab or crust that indicates deeper tissue damage and is not observed in Stage II pressure ulcers.

Choice B rationale

A Stage II pressure ulcer is characterized by partial thickness skin erosion with loss of the epidermis and dermis. It appears as a shallow open ulcer with a red-pink wound bed, indicating that the damage has not extended beyond these layers of skin.

Choice C rationale

When a pressure ulcer extends into the subcutaneous tissue, it is classified as a Stage III or IV ulcer, depending on the depth and extent of tissue involvement. Stage II ulcers are limited to the epidermis and dermis and do not reach the subcutaneous layer.

Choice D rationale

Intact skin that appears red but is not broken is indicative of a Stage I pressure ulcer, which represents the earliest stage of pressure injury. Stage I ulcers involve non-blanchable erythema (redness) but no open wound or skin erosion.

Choice E rationale

Open blister areas with a red-pink wound bed are characteristic of Stage II pressure ulcers. These ulcers exhibit partial thickness skin loss and can present as open or fluid-filled blisters with a visible wound bed.

Choice F rationale

Localized redness in light skin that blanches with fingertip pressure is typical of a Stage I pressure ulcer. Blanching erythema indicates that the skin is still viable and blood flow is present, which differentiates Stage I from more advanced stages of pressure injury.

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 A

Explanation

Choice A rationale

The general survey is an overall assessment of a client's physical appearance, behavior, mobility, and neurological status. It provides a comprehensive overview of the client's health and well-being, making it the focus of the nurse's observations in this scenario.

Choice B rationale

Medical history includes past and current health conditions, surgeries, medications, and family health history. While important, it is not the focus of the nurse's immediate observations in this scenario.

Choice C rationale

Biographical data involves personal information such as age, gender, occupation, and marital status. While relevant to the client's health, it is not the primary focus of the nurse's observations in this scenario.

Choice D rationale

Social history includes information about the client's lifestyle, habits, and social environment. While valuable for understanding the client's overall health context, it is not the focus of the nurse's immediate observations in this scenario. .

A. Rhonchi. B. Wheeze. C. Crackles. D. Stridor.

Correct Answer is A

Explanation

Choice A rationale

Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.

Choice B rationale

Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.

Choice C rationale

Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.

Choice D rationale

Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .

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 patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices the client's physical appearance, behavior, mobility, and neurological status when they enter the room.Which of the following is the nurse assessing?

Correct Answer is A

Explanation

After auscultating which adventitious breath sound should the nurse have the patient cough and then auscultate again?

Correct Answer is A

Explanation

A nurse is caring for a patient diagnosed with cataracts.What cue is consistent with cloudiness in the lens during the inspection of the eyes?

During cardiac examination of a client, the nurse was demonstrating to the student nurse where to locate the Angle of Louis to listen to the Aortic and Pulmonic area on the chest.The nurse should locate the Angle of Louis at the level of what rib?

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts.The nurse should expect the client to report:

A nurse is assessing cranial nerve VIII.What tests will be administered on the client?

The daughter of an elderly client diagnosed with macular degeneration asks the nurse to explain this disorder.In formulating a response, the nurse would include information that this condition is characterized by which of the following?

The nurse is assessing the peripheral vascular system of a client.On inspection, the client's legs are cold and the client reports she no longer has hair growing on the legs.What does the nurse suspect the client is experiencing?

Which of the following are considered normal findings for assessment of the respiratory system? Select all that apply.

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.The nurse examines the sacral ulcer and determines it is a Stage II ulcer.Which of these findings is characteristic of a Stage II pressure ulcer?

A patient has been admitted to the hospital after the staff at a nursing home noticed a pressure ulcer on his sacral area.
The nurse examines the sacral ulcer and determines it is a Stage II ulcer.
Which of these findings is characteristic of a Stage II pressure ulcer?