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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.

Stage IV

B.

Stage I

C.

Stage III

D.

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.


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Related Questions

Correct Answer is C

Explanation

A. 4, 3, 2, 1 (Pulmonic → Tricuspid → Aortic → Mitral): This sequence incorrectly places the pulmonic valve first instead of the tricuspid.

B. 1, 3, 2, 4 (Mitral → Tricuspid → Aortic → Pulmonic): This sequence incorrectly starts with the mitral valve (left side of the heart), instead of the tricuspid (right side of the heart).

C. 3, 4, 1, 2 (Tricuspid → Pulmonic → Mitral → Aortic): Blood flow through heart valves follows this order:

  1. Tricuspid Valve (Right atrium → Right ventricle)
  2. Pulmonic Valve (Right ventricle → Pulmonary artery → Lungs)
  3. Mitral Valve (Left atrium → Left ventricle)
  4. Aortic Valve (Left ventricle → Aorta → Body)

D. 2, 4, 1, 3 (Aortic → Pulmonic → Mitral → Tricuspid): This sequence incorrectly places the aortic valve first, which is incorrect for blood flow through the heart.

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.

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