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","E"]

Explanation

A. Amber or dark-colored urine is a sign of dehydration and indicates a decrease in fluid volume.

B. A weak, thready pulse is often seen in clients with hypovolemia due to reduced circulating blood volume.

C. Distended neck veins are a sign of fluid overload, not hypovolemia.

D. Bradycardia is typically not associated with hypovolemia; tachycardia is more common.

E. Decreased capillary refill is indicative of reduced perfusion, a symptom of hypovolemia.

A. Heart murmurs (S3, S4) B. Breath sounds C. Normal heart (S1,S2) D. Bowel sounds

Correct Answer is A

Explanation

A. The bell of the stethoscope is used to detect low-pitched sounds such as heart murmurs (S3 and S4).

B. Breath sounds are typically auscultated using the diaphragm of the stethoscope.

C. Normal heart sounds (S1, S2) are best heard using the diaphragm of the stethoscope.

D. Bowel sounds are auscultated using the diaphragm, not the bell.

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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

A nurse is caring for an older adult client. The nurse suspects that the client may be experiencing hypovolemia. For which clinical indicators should the nurse assess the dient that supports this conclusion? (Select All That Apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Correct Answer is A

Explanation

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