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: Carbohydrates are important for energy but do not specifically promote wound healing.

Choice B rationale: Vitamin C is crucial for collagen synthesis and wound healing, so an increased intake is beneficial.

Choice C rationale: Calcium is important for bone health but does not have a direct role in promoting wound healing.

Choice D rationale: Vitamin E has antioxidant properties but is not the primary nutrient emphasized for wound healing.

A. tell the nurse manager. B. notify the physician. C. check the client's blood pressure. D. file an incident report.

Correct Answer is C

Explanation

Choice A rationale: Telling the nurse manager is not the first action; the immediate focus should be on the client's well-being.

Choice B rationale: Notifying the physician is important, but the immediate concern is addressing the client's condition.

Choice C rationale: Checking the client's blood pressure is the first action to assess the client's response to the medication error.

Choice D rationale: Filing an incident report is important for documenting the error but is not the immediate action in this situation.

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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 client has had a surgical debridement of a wound, which is starting to heal. In order to further promote healing, this client should be encouraged to consume a balanced diet with emphasis on increased:

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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.