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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This instruction is more appropriate for female clients performing perineal hygiene before providing a clean-catch urine specimen. For straight catheterization, the nurse typically performs sterile technique, including cleansing the urethral meatus with an antiseptic solution as part of the procedure. The client's perineal area may be cleansed if necessary, but the primary focus is on maintaining sterile technique during catheter insertion.
B. When performing straight catheterization, the nurse inserts a sterile catheter into the client's bladder via the urethra to obtain urine directly. The urine is collected from the catheter itself as it drains into a sterile specimen container. It's essential to avoid touching the catheter's port or allowing it to come into contact with non-sterile surfaces to prevent contamination.
C. When inserting a Foley catheter (indwelling catheter), sterile water is used to inflate the balloon at the tip of the catheter after insertion into the bladder. For straight catheterization, a balloon is not typically inflated because the catheter is removed immediately after urine is obtained. Therefore, this step is not applicable in this context.
D. It is crucial to use a sterile specimen container to collect urine obtained via straight catheterization. This ensures that the specimen remains uncontaminated and suitable for culture and sensitivity testing, which requires accurate identification of any bacteria present in the urine.
Correct Answer is ["2"]
Explanation
To administer a dose of 10 mg of olanzapine using 5 mg tablets, the nurse would need to give two (2) tablets
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