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. Repositioning the client regularly is a critical measure to prevent pressure ulcers. This helps relieve pressure on vulnerable areas of the body and improves circulation. Turning the client every 2 hours is a common guideline to prevent prolonged pressure on any one area.
B. Keeping the head of the bed elevated continuously is not recommended as it can increase shear and friction, leading to skin breakdown.
C. Keeping the client's skin moisturized is important for maintaining skin integrity, but excessive moisture can increase the risk of skin breakdown, especially in areas susceptible to pressure ulcers. The nurse should aim to keep the skin clean, dry, and free from excessive moisture to prevent maceration.
D. Massaging bony prominences is not recommended as a preventive measure for pressure ulcers. In fact, massaging these areas can increase the risk of tissue damage due to friction and shearing forces. The focus should be on relieving pressure through proper positioning and support surfaces rather than massage.

A. Decreased hematocrit B. Increased urine ketones C. Increased urine specific gravity D. Decreased BUN

Correct Answer is C

Explanation

A. Hematocrit measures the percentage of red blood cells in the blood. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, resulting in an increase in hematocrit rather than a decrease. Therefore, a decreased hematocrit would not be an expected finding in fluid volume deficit.
B. Urine ketones are typically elevated in conditions where there is increased fat metabolism, such as in diabetic ketoacidosis or starvation. They are not directly related to fluid volume deficit and would not be an expected finding.
C. Urine specific gravity measures the concentration of solutes in the urine, indicating the kidney's ability to concentrate or dilute urine. In fluid volume deficit, the body conserves water, leading to increased urine concentration and higher urine specific gravity. Therefore, increased urine specific gravity is an expected finding in fluid volume deficit.
D. BUN is a measure of kidney function and protein metabolism. In fluid volume deficit, there is hemoconcentration due to decreased fluid volume, which can lead to an increase in BUN rather than a decrease. A decreased BUN would not typically be an expected finding in fluid volume deficit.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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