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 B

Explanation

Choice A rationale
Withholding the medication until the prescribing provider is available could potentially put the patient at risk, especially if the medication is critical for the patient’s health and well-being.
Choice B rationale
Requesting to speak with the provider who is covering for the prescriber is the most appropriate action in this situation. This allows the nurse to clarify the prescription and ensure the safety of the patient.

Choice C rationale
Contacting the pharmacy to confirm that the dosage is safe to administer could be a part of the process, but it should not be the first step. The nurse should first contact a healthcare provider to discuss the prescription.
Choice D rationale
Informing the charge nurse and administering the usual dose of the medication without first consulting with a healthcare provider could potentially put the patient at risk.

A. A client who has community-acquired pneumonia with copious respiratory secretions B. A client who has AIDS and is coughing up blood C. A client who has Guillain-Barré syndrome and is on a ventilator D. A client who has bronchitis and a tracheostomy

Correct Answer is A

Explanation

Choice A rationale
A client who has community-acquired pneumonia with copious respiratory secretions should be assigned to the private room. This is because pneumonia, especially with copious respiratory secretions, can be transmitted through the air, and therefore requires airborne precautions.
Choice B rationale
A client who has AIDS and is coughing up blood may not necessarily require a private room for airborne precautions. While AIDS is a serious condition, it is not primarily transmitted through the air. Instead, it is transmitted through direct contact with bodily fluids, particularly blood, semen, vaginal fluids, and breast milk.
Choice C rationale
A client who has Guillain-Barré syndrome and is on a ventilator would not necessarily require a private room for airborne precautions. Guillain-Barré syndrome is a neurological disorder, not an infectious disease, and it is not transmitted from person to person.
Choice D rationale

A client who has bronchitis and a tracheostomy may not necessarily require a private room for airborne precautions. While bronchitis can be caused by an infection, it is typically transmitted through direct contact or droplet transmission, not through the air.

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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 reviewing a client’s prescriptions and notices that the dosage of one medication is three times the usual dose.The prescribing provider is unavailable for several days. What should the nurse do next?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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