When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a
dropdown
pressure ulcer.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B"}

Choice A rationale: Stage I pressure ulcers involve intact skin with non-blanchable redness, and there is no mention of intact skin in the scenario.

Choice B rationale: Stage II pressure ulcers involve partial thickness skin loss, typically presenting as an abrasion, blister, or shallow crater, which aligns with the description provided.

Choice C rationale: Stage III pressure ulcers involve full-thickness skin loss with damage to or necrosis of subcutaneous tissue but do not match the described scenario.

Choice D rationale: Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, which does not align with the description of partial thickness skin loss in the scenario.

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Correct Answer is B

Explanation

Choice A rationale: Propranolol 10 mg PO twice a day would typically be given with a more extended interval between doses, not at 10:00 AM, 2:00 PM, and 6:00 PM.
Choice B rationale: Diazepam 5 mg PO three times a day would align with the specified dosing schedule of 10:00 AM, 2:00 PM, and 6:00 PM.
Choice C rationale: Cephalexin 500 mg PO q4 hours would require more frequent dosing than the specified schedule.
Choice D rationale: Morphine Sulfate 10 mg IM q4 hours prn pain is ordered every 4 hours, not at the specified times of 10:00 AM, 2:00 PM, and 6:00 PM.

A. potassium 4.2 mEq/L B. phosphate 3.0 mg/dL C. magnesium 1.8 mEq/L D. calcium 6.9 mg/dL E. calcium 6.9 mg/dL

Correct Answer is D

Explanation

Choice A rationale: A potassium level of 4.2 mEq/L is within the normal range and would not validate Trousseau's and Chvostek's signs.

Choice B rationale: A phosphate level of 3.0 mg/dL is within the normal range and would not validate Trousseau's and Chvostek's signs.

Choice C rationale: A magnesium level of 1.8 mEq/L is within the normal range and would not validate Trousseau's and Chvostek's signs.

Choice D rationale: A calcium level of 6.9 mg/dL is below the normal range and could validate Trousseau's and Chvostek's signs.

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When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a dropdown pressure ulcer.

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Naxlex Comprehensive Predictor Exams

The nurse is transcribing a medication order and schedules dosing for 10:00 AM, 2:00 PM and 6:00 PM. Which medication order is consistent with this schedule?

Correct Answer is B

Explanation

The nurse is assessing a client who exhibits positive Trousseau's and Chvostek's signs. What laboratory value would validate these clinical findings? A serum:

Correct Answer is D

Explanation

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On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a
dropdown
pressure ulcer.