Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

There appears to be persistent reddening of the skin.

There is a fluid-filled area under the skin.

There is full-thickness skin loss with a crater.

There is slough on part of the wound area.

Answer and Explanation

The Correct Answer is C

A.   This description is more indicative of a stage 1 pressure ulcer, where the skin is intact but shows non- blanchable redness. Stage 1 ulcers do not involve skin loss.
B.   This description might indicate a stage 2 pressure ulcer, where there is partial-thickness skin loss involving the epidermis and/or dermis. Stage 2 ulcers are characterized by shallow open ulcers with a red- pink wound bed, without slough.
C.   This description accurately defines a stage 3 pressure ulcer. Stage 3 ulcers involve full-thickness skin loss where adipose (fat) tissue may be visible, but deeper structures such as muscle, tendon, and bone are not exposed.
D.   Slough refers to yellow, tan, gray, green, or brown necrotic tissue in the wound bed that must be removed to facilitate wound healing. Slough can be present in both stage 3 and stage 4 pressure ulcers, where stage 4 involves full-thickness skin loss with exposure of muscle, bone, or supporting structures.

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Correct Answer is A

Explanation

A. Body weight is one of the most reliable indicators of fluid status in a dialysis patient. Before and after each hemodialysis session, the nurse should weigh the client using the same scale under similar conditions (e.g., same clothing). The difference in weight reflects fluid loss during the dialysis treatment. This measurement helps guide adjustments in fluid management and dialysis prescriptions.
B. Abdominal girth can increase due to fluid accumulation in the abdomen (ascites) but is less specific for measuring fluid losses during dialysis. It may be more indicative of fluid retention over a longer period rather than immediate changes related to a single dialysis session.
C. Neck vein distention can be a sign of fluid overload but is not typically used to assess fluid losses during dialysis. It may be more relevant for assessing fluid status over time rather than immediate changes post- dialysis.
D. Blood pressure can fluctuate based on various factors, including fluid status. While blood pressure monitoring is essential in dialysis patients, it alone does not reliably reflect fluid losses during dialysis sessions.

A. To promote digestion B. To regulate blood pressure C. To reduce inflammation D. To enhance the immune system

Correct Answer is A

Explanation

A. Ginger is well-known for its ability to promote digestion. It can help alleviate nausea, improve gastric motility, and reduce bloating or discomfort associated with gastrointestinal issues such as a bowel obstruction. Therefore, the client's request for hot ginger tea likely aims to promote digestion, making option A a plausible choice.
B. Ginger is not typically used to regulate blood pressure. Its primary effects are related to digestion, anti- inflammatory properties, and potential immune system support, rather than directly affecting blood pressure regulation.
C. Ginger has anti-inflammatory properties, which can be beneficial in reducing inflammation in the body. However, in the context of the client's request for ginger tea after recovering from a bowel obstruction, the immediate purpose is more likely related to its digestive benefits rather than general anti- inflammatory effects.
D. Ginger has some antioxidant and immune-modulating properties that may contribute to enhancing the immune system. However, its use in Chinese culture, particularly as a tea, is traditionally more associated with digestive health rather than immune enhancement.

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Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving hemodialysis. Which of the following client measurements should the nurse compare before and after dialysis treatment to determine fluid losses?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

Correct Answer is A

Explanation

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