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. Agitation can be a manifestation of hypoxia. As the body senses inadequate oxygen supply, it may respond with restlessness or agitation as a compensatory mechanism to increase oxygen intake.
B. Nausea is not a typical finding in hypoxia.
C. Dysphagia refers to difficulty swallowing and is not typically associated with hypoxia. It is more commonly related to neurological or structural issues affecting the swallowing mechanism.
D. Warm, dry skin is not a typical manifestation of hypoxia. In fact, hypoxia often results in cool, clammy, or cyanotic (bluish) skin due to inadequate oxygen perfusion.

A. Protein B. Tea C. Sodium D. Water

Correct Answer is D

Explanation

A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney

stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.

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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 reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has received treatment for kidney stones. The nurse should remind the client to increase intake of which of the following?

Correct Answer is D

Explanation

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