The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Stage IV
Stage I
Stage III
Stage II
The Correct Answer is D
A. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV.
B. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I.
C. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.
D. Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.
B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.
C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.
D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.
Correct Answer is D
Explanation
A. "I will treat all the family members to be on the safe side." Treatment is only recommended for individuals who have active lice or close, prolonged contact with the infected child. Treating everyone unnecessarily may lead to overuse of medications.
B. "My child must be free from nits before returning to school." The CDC and AAP do not recommend "no-nit" policies, as nits alone do not indicate active infestation. Children can return to school after appropriate treatment begins.
C. "Toys that can't be dry cleaned or washed must be thrown out." Non-washable items should be sealed in a plastic bag for 2 weeks to kill lice, rather than being thrown away.
D. "All recently used clothing, bedding, and towels must be washed in hot water." Lice and nits can survive on fabric surfaces, so washing clothing, bedding, and towels in hot water (≥130°F/54°C) and drying on high heat is recommended to eliminate them.
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