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
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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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Carbon dioxide level is not a direct indicator of the blood's ability to transport oxygen.
Choice B rationale: Surfactant level is not a direct indicator of the blood's ability to transport oxygen; surfactant is related to lung function.
Choice C rationale: Bicarbonate ion level is more related to acid-base balance and not a direct indicator of the blood's ability to transport oxygen.
Choice D rationale: Hemoglobin level provides the most information about the blood's ability to transport oxygen, as hemoglobin carries oxygen to tissues.
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale: Hypernatremia involves elevated sodium levels, so encouraging potassium-rich foods is not directly related to addressing hypernatremia.
Choice B rationale: Restricting sodium in the diet is appropriate to help manage and reduce hypernatremia. This can prevent further complications of hypernatremia, such as dehydration, confusion, seizures, and coma.
Choice C rationale: This is not an appropriate intervention for hypernatremia, as water intake can help dilute the sodium levels and restore the fluid balance in the body.
Decreasing water intake can worsen the hypernatremia and cause dehydration. Choice D rationale: This is an appropriate intervention for hypernatremia, as high sodium levels can affect the fluid balance and blood pressure in the body. Monitoring
vital signs can help detect any changes or abnormalities that may indicate worsening of the condition or need for further treatment.
Choice E rationale: Monitoring intake and output helps assess fluid balance and response to interventions for hypernatremia.
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