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 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.

A. Complete an incident report. B. Assess the client. C. Notify the nurse manager. D. Call the client's provider.

Correct Answer is B

Explanation

A. Completing an incident report is important but comes after ensuring the client's safety.

B. The priority is assessing the client for any adverse reactions or complications related to the incorrect medication.

C. Notifying the nurse manager should follow after the assessment and client stabilization.

D. The provider should be notified after assessing the client and identifying any clinical concerns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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Correct Answer is B

Explanation

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