During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

An area of erythema that is painful to touch.

Shallow open ulcer with a red pink wound bed.

A deep pocket of infection and necrotic tissues.

Visible subcutaneous tissue with sloughing.

Answer and Explanation

The Correct Answer is B

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

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 D

Explanation

A. Renal creatinine clearance is important in assessing kidney function but is not directly related to divalproex sodium therapy.
B. While CBC monitoring is essential, especially for detecting thrombocytopenia, liver function tests are more critical in this context.
C. A chemistry panel is valuable but does not specifically monitor for the primary risks associated with divalproex sodium.
D. Divalproex sodium (valproate) can cause hepatotoxicity, so monitoring liver function tests (LFTs) is crucial. Regular LFTs help detect early signs of liver damage, which can be a serious adverse effect of this medication.

A. Demonstrate how to select dose based on before meal blood sugar readings. B. Teach the client self-injection skills for daily subcutaneous administration. C. Provide information on increasing medication dosage if ketoacidosis occurs. D. Explain to the family how to inject this medication for severe hypoglycemia.

Correct Answer is B

Explanation

A. Insulin glargine is a long-acting insulin, and its dose is not based on before-meal blood sugar readings.
B. The client needs to be taught how to self-administer insulin glargine, as it is given subcutaneously once daily, usually at the same time each day.
C. Increasing the dosage in response to ketoacidosis is inappropriate; emergency treatment is required for this condition.
D. Insulin glargine does not have a role in treating severe hypoglycemia; fast-acting glucose or glucagon is used for such situations.

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

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

Correct Answer is D

Explanation

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

Correct Answer is B

Explanation

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

Which client is at greatest risk for aspiration?

Which intervention is most important for the nurse to implement when administering medications?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?