The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

Stage IV

Stage II

Stage III

Unstageable

Answer and Explanation

The Correct Answer is D

D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable

A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.

B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.

C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.

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

Explanation

A. External rotation of the hip involves rotating the thigh outward away from the midline of the body. This movement occurs in the hip joint. External rotation is a component of hip range of motion.

B. Extension of the hip involves moving the thigh backward, straightening the leg from a flexed position. This movement also occurs in the hip joint. Extension is part of the hip's range of motion.

C. Adduction of the hip involves moving the thigh toward or across the midline of the body. It brings the leg closer to the midline. Adduction is another movement that is part of the hip's range of motion.

E. Flexion of the hip involves bringing the thigh toward the abdomen or bending the leg. It is a movement where the angle between the thigh and the abdomen decreases. Flexion is a fundamental movement of the hip joint.

D. Supination is a movement primarily associated with the forearm and hand, involving turning the palm upward or facing forward. It is not a movement of the hip joint. Supination is not correct in the context of hip range of motion.

A. ibuprofen liquid 300 mg Q 6 hours prn for pain B. potassium chloride XL 40 mEq daily C. levothyroxine 25 mcg daily D. multivitamin liquid 10 mL daily

Correct Answer is B

Explanation

B.This formulation is not intended for administration through a gastrostomy tube and could be harmful to the patient. It is essential to consult with a pharmacist or physician to find a suitable alternative that is safe for administration through the gastrostomy tube

A. Ibuprofen is typically administered orally (PO) and is absorbed in the gastrointestinal tract.

C. Levothyroxine is a thyroid hormone replacement medication crucial for maintaining thyroid hormone levels in individuals with hypothyroidism. It is typically administered orally in the morning on an empty stomach to ensure optimal absorption.

D. Liquid formulations are suitable for administration through gastrostomy tubes, as they are generally well-tolerated and absorbed.

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The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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