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. This statement is incorrect because after instilling ointment, the client should close their eye gently and avoid blinking to allow the ointment to spread over the conjunctival sac.
B. When applying ophthalmic ointment, the client should pull down the lower eyelid to create a small pocket (conjunctival sac) and then apply a thin line of ointment along this pocket. This method helps the ointment distribute evenly over the affected area.
C. While this is a correct technique for cleaning around the eye, it is not directly related to the application of ophthalmic ointment.
D. This statement is unnecessary and may confuse the client. It's typically not required to use sterile gloves for applying ophthalmic ointment, and most ointments come with a sterile applicator or can be applied using clean hands if instructed to do so by a healthcare provider.

A. Standing with his feet close together when lifting B. Keeping the box close to his body as he lifts it C. Bending at the waist to pick up the box D. Twisting to place the box to his side

Correct Answer is B

Explanation

A. Standing with feet close together reduces the base of support, making the nurse less stable and increasing the risk of losing balance or straining muscles. It is not recommended for lifting because it compromises stability and balance.
B. Keeping the box close to the body reduces the leverage and strain on the back muscles. This technique utilizes the strength of the legs and core muscles more effectively and helps to maintain balance and stability while lifting.
C. Bending at the waist puts excessive strain on the lower back muscles and can lead to back injury, especially when lifting heavy objects. The correct technique is to bend at the knees and hips while keeping the back straight to maintain proper alignment and reduce strain on the spine.
D. Twisting while lifting or carrying heavy objects can strain the muscles and ligaments of the spine, leading to injury, particularly to the intervertebral discs. The nurse should avoid twisting and instead pivot the entire body with the feet to change direction.

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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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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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