Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

There is slough on part of the wound area.

There appears to be persistent reddening of the skin.

There is full-thickness skin loss with a crater.

There is a fluid-filled area under the skin.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

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Correct Answer is A

Explanation

Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale

Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.

A. Tachycardia. B. Poor skin turgor. C. Excessive pulmonary secretions. D. Cracks in oral mucous membranes.

Correct Answer is D

Explanation

Choice A rationale
Tachycardia is not a common adverse effect of oxygen therapy. It is more likely to be associated with conditions such as fever, anemia, or hypoxia.
Choice B rationale
Poor skin turgor is a sign of dehydration, not a typical adverse effect of oxygen therapy. Oxygen therapy does not directly affect the body’s hydration status.
Choice C rationale
Excessive pulmonary secretions are not a direct adverse effect of oxygen therapy. Conditions such as pneumonia or bronchitis often cause increased secretions.

Choice D rationale
Cracks in the oral mucous membranes can occur as a result of oxygen therapy. Oxygen can dry out the mucous membranes, leading to discomfort and potential cracking.

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Upon inspecting a client’s skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which statement best describes a stage 3 pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing home safety instructions for a patient with a history of falls. Which statement should the nurse identify as an indication that the patient understands the instructions?

Correct Answer is A

Explanation

A nurse is caring for a patient with pneumonia who has been on oxygen therapy for several days. Which of the following symptoms should the nurse recognize as a potential adverse effect of oxygen therapy?

Correct Answer is D

Explanation

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