The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

Debride the wound.

Manage drainage from the wound.

Document the wound.

Monitor the wound.

Answer and Explanation

The Correct Answer is A

A: Debriding the wound is the next step for a black (necrotic) pressure ulcer. Removing the dead tissue is essential to promote healing and prevent infection.

B: Managing drainage is important for wound care but is not the immediate next step for a necrotic ulcer.

C: Documenting the wound is necessary but does not address the need for debridement.

D: Monitoring the wound is important, but active intervention (debridement) is required for a necrotic ulcer to promote healing.

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Correct Answer is B

Explanation

A: Completing proper documentation of the medication error is important but should not be the first action. Immediate assessment of the patient is more critical.

B: Returning to the room to check and assess the patient is the first priority. The nurse needs to determine if the patient has experienced any adverse effects from the medication error and provide appropriate care.

C: Administering the antidote to the patient immediately is only necessary if the medication given has a known antidote and the patient is showing signs of adverse effects. Assessment should come first.

D: Alerting the charge nurse that a medication error has occurred is important for reporting and follow-up but should follow the immediate assessment and care of the patient.

A. Hyperkalemia B. Hyponatremia C. Hypervolemia D. Hypovolemia

Correct Answer is C

Explanation

A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.

B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.

C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.

D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.

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The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which action should the nurse complete first?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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