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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.
A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.
B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.
C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.
Correct Answer is D
Explanation
D. This statement exemplifies the ethical principle of fidelity, also known as faithfulness or commitment. Fidelity involves keeping promises, being reliable, and fulfilling commitments made to patients. By returning promptly with the pain medication as promised, the nurse demonstrates fidelity by honoring their commitment to the patient's care and comfort.
A. This statement reflects the ethical principle of justice, which emphasizes fairness and equality in treatment for all patients. Justice ensures that resources and treatments are distributed fairly among individuals.
B This statement demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm and minimizing risks to patients. It emphasizes the nurse's commitment to avoiding harm or injury to the patient.
C. This statement relates to truth-telling or veracity, which involves providing honest and accurate information to patients about their care, procedures, and potential outcomes. It reflects transparency and respect for patient autonomy.
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