The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Stage III

unstageable

necrotic stage I

stage II

Answer and Explanation

The Correct Answer is B

A.   Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B.   The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C.   The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

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Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

The increase in axillary temperature to 100.5° F is significant and could indicate an infection or other inflammatory process. The heart rate has increased to 105/min, which, along with the reported symptoms of heat intolerance, nervousness, and irregular heartbeat during exercise, may suggest an endocrine disorder such as hyperthyroidism. The significant weight loss of 20 pounds in a month without changes in diet or physical activity is also concerning and warrants further investigation. The patient's history of having a bowel movement after every meal could be related to the reported diarrhea and should be explored further.

A. Inspect the nailbeds for the presence of clubbing. B. Inspect the nailbeds and mucous membranes for the presence of cyanosis. C. Palpate for areas of decreased tactile fremitus. D. Auscultate for the presence of any adventitious breath sounds.

Correct Answer is B

Explanation

A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.

B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.

C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.

D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.

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The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

You are examining a client with respiratory distress. Which physical assessment would best determine if the client has acute hypoxemia?

Correct Answer is B

Explanation

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