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 B

Explanation

A. Performing a blind finger sweep involves inserting a finger into the client's mouth to try and remove an obstruction. This action is not recommended because it can push the obstruction further down the airway, potentially worsening the situation and causing the client to choke.
B. The Heimlich maneuver (abdominal thrusts) is a technique used to clear an obstructed airway in conscious adults. It involves applying sudden upward pressure on the abdomen, between the navel and ribcage, to force air from the lungs to dislodge the obstruction.
C. Turning the client to the side is typically done if the client is unconscious and not breathing normally (recovery position). This position helps maintain a clear airway by allowing any fluids or vomit to drain out of the mouth and prevent obstruction.
D. Tilting the head and lifting the chin is part of the head-tilt, chin-lift maneuver used to open the airway. This maneuver is used when a client is unconscious or unresponsive but breathing. It helps to keep the airway open by lifting the tongue away from the back of the

Correct Answer is ["15"]

Explanation

750 mg (desired dose) divided by 250 mg (available concentration) equals 3. This result is then multiplied by the volume that contains 250 mg, which is 5 mL. So, 3 times 5 mL equals 15 mL.

Therefore, the nurse should plan to administer 15 mL of the valproate oral solution

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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?

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A nurse is caring for a client who is conscious and has an airway obstruction. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is ["15"]

Explanation

A nurse is preparing to administer dextrose 5% in water (DSW) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

An assistive personnel (AP) asks a nurse what precautions he should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client with bacterial conjunctivitis of the right eye, and a prescription for an antibiotic ophthalmic ointment. Which of the following statements should the nurse make?

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?