The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Stage 1 pressure ulcer

Stage 4 pressure ulcer

Stage 2 pressure ulcer

Stage 3 pressure ulcer

Answer and Explanation

The Correct Answer is D

A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.

B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.

C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.

D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.

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Correct Answer is A

Explanation

A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.

B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.

C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.

D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.

A. A postoperative client whose blood pressure at 0800 was 138/86 mm Hg and now at 1000 is 90/60 mm Hg B. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 100 mg/dL C. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous D. A client who reports pain as 1 on a scale of 1 to 10 at 0800 now reports pain as 3

Correct Answer is A

Explanation

A. A significant drop in blood pressure from 138/86 mm Hg to 90/60 mm Hg indicates potential hypovolemia or hemorrhage, which requires immediate intervention to prevent shock or other complications. This is the most critical finding among the clients.

B. A client with stable blood glucose levels between 110 mg/dL and 100 mg/dL is not a priority, as these readings are within a normal range and do not indicate immediate danger.

C. The transition of wound drainage from sanguineous to serosanguineous is a normal part of the healing process and is not an urgent concern.

D. A mild increase in pain from 1 to 3 on a 1 to 10 scale is also not an immediate priority, as it remains within a low pain range and can be managed with routine pain control measures.

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The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

Correct Answer is A

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

. A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take?

The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?

A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?

A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?

A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)