The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?

The ulcer has thick dark eschar over the top

Exposed bone/tendon is visible

There is partial-thickness loss of dermis

The wound extends into the subcutaneous tissue.

Answer and Explanation

The Correct Answer is B

B. This finding suggests deep tissue involvement and is characteristic of a Stage IV pressure injury. Stage IV pressure injuries involve full-thickness tissue loss with exposure of underlying structures such as bone, tendon, or muscle. This level of tissue damage requires extensive wound care and management to promote healing.

A. Thick dark eschar indicates necrotic tissue that typically covers the wound. While eschar itself is a characteristic of severe wounds, its presence alone does not define a Stage IV pressure injury. Eschar can be present in various stages of pressure injuries.

C. Partial-thickness loss of dermis typically corresponds to Stage II pressure injuries, where the injury extends into the epidermis and dermis but does not yet involve full-thickness tissue loss. This finding does not indicate a Stage IV pressure injury.

D. This finding is characteristic of a Stage III pressure injury, where the wound extends through the dermis into the subcutaneous tissue layer. In Stage IV pressure injuries, the damage progresses further to involve deeper structures such as muscle and bone, beyond the subcutaneous tissue.

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Correct Answer is A

Explanation

A. This is the most direct and appropriate question to assess for dysuria. Dysuria is characterized by pain, discomfort, or burning sensation during urination. Asking this question helps the nurse to directly assess if the client is experiencing these symptoms.

B. This question is more relevant for assessing urinary frequency rather than dysuria. It is important for assessing other urinary symptoms but does not specifically address the characteristic pain or discomfort associated with dysuria.

C. This question is pertinent for assessing urinary retention or incomplete emptying of the bladder, which are different concerns from dysuria. It evaluates the client's perception of bladder emptying rather than pain or discomfort during urination.

D. This question is more relevant for assessing urinary hesitancy or urgency, which are related to bladder function but are not specific to dysuria. It addresses issues with urine flow dynamics rather than pain or discomfort during urination.

A. respiratory alkalosis. B. respiratory acidosis. C. metabolic acidosis. D. metabolic alkalosis.

Correct Answer is D

Explanation

D. Metabolic alkalosis is characterized by an increased pH (alkalosis) and an increased HCO3. In this case, the pH is elevated (7.5), indicating alkalosis, which supports metabolic alkalosis. The HCO3 is elevated at 40 mEq/L, which further supports metabolic alkalosis. The PaCO2 is normal or slightly low (36 mmHg), which can occur as a compensatory response to metabolic alkalosis.

A. Respiratory alkalosis is characterized by an increase in pH (alkalosis) and a decrease in PaCO2 (hypocapnia). In this scenario, the pH is elevated (7.5), which indicates alkalosis. The PaCO2 is 36 mmHg, which is within the normal range (35-45 mmHg) but slightly on the lower side (slight hypocapnia). The HCO3 is elevated at 40 mEq/L, which suggests a compensatory response by the kidneys to retain bicarbonate to counteract the alkalosis.

B. Respiratory acidosis is characterized by a decrease in pH (acidosis) and an increase in PaCO2 (hypercapnia). In this case, the pH is elevated (7.5), indicating alkalosis, which contradicts respiratory acidosis. The PaCO2 is 36 mmHg, which is normal or slightly low, not high as expected in respiratory acidosis. The elevated HCO3 (40 mEq/L) suggests a compensatory metabolic response to the alkalosis, not to acidosis.

C. Metabolic acidosis is characterized by a decreased pH (acidosis) and a decreased HCO3. In this scenario, the pH is elevated (7.5), indicating alkalosis, which contradicts metabolic acidosis. The HCO3 is elevated at 40 mEq/L, indicating metabolic alkalosis rather than metabolic acidosis.

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The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the client for the presence of dysuria. The nurse should ask: "Do you:

Correct Answer is A

Explanation

A client is admitted to the medical-surgical unit with a chief complaint of prolonged vomiting over the past 24 hours. Based on the arterial blood gas (ABG) results of pH 7.5. PaCO2 36, HCO3 40, the nurse determines that the client is experiencing:

Correct Answer is D

Explanation

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