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

Answer and Explanation

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

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 B

Explanation

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed. Pain is subjective and should always be believed and assessed rather than dismissed based on procedure type. This does not demonstrate critical thinking.

B. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked best in the past. This approach assesses the patient’s individual experience and applies personalized care, which is a hallmark of critical thinking.

C. Administering pain-relief medication according to what was given last shift. Pain levels fluctuate, and medication effectiveness must be reassessed each time. Simply repeating the previous shift’s orders does not involve critical thinking.

D. Offering pain-relief medications based on the provider’s orders. While following orders is necessary, critical thinking involves assessing the patient’s pain level and determining the most appropriate intervention rather than blindly administering medication.

Correct Answer is ["37"]

Explanation

98.6 - 32) × 5/9 = 37°C
Answer: 37°C

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Correct Answer is B

Explanation

Convert from Fahrenheit to Celsius: 98.6

Correct Answer is ["37"]

Explanation

A nurse is teaching a client who has a new prescription for diphenhydramine for allergic rhinitis. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? (Select all that apply.)

The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

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?

A patient who has been taking antihypertensive drugs for a few months states that a new, persistent dry cough is very bothersome. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?

The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed?

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?