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 stage pressure ulcer.

Answer and Explanation

The Correct Answer is D

A. Stage 4 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.

B. Stage 3 pressure ulcers involve full-thickness skin loss with visible fat but no exposed bone, tendon, or muscle.

C. Stage 1 pressure ulcers involve intact skin with non-blanchable redness.

D. Stage 2 pressure ulcers involve partial thickness skin loss, typically presenting as an abrasion, blister, or shallow crater, which aligns with the description provided.

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Correct Answer is D

Explanation

A. Delegation may not directly affect the prediction of overtime costs.

B. Delegation can help alleviate pressure on individual nurses by distributing tasks appropriately.

C. Delegation should not result in clients receiving less attention; rather, it should ensure that tasks are completed efficiently and effectively.

D. Delegation allows for the efficient use of nursing staff skills, ensuring that tasks are performed by the appropriate personnel, which can improve overall effectiveness and client outcomes.

A. chloride 100 mEq/L B. hematocrit 44%. C. potassium 3.2 mEq/L D. sodium 142 mEq/L

Correct Answer is C

Explanation

A. A chloride level of 100 mEq/L is within the normal range and may not require immediate attention.

B. A hematocrit of 44% is within the normal range and may not require immediate attention.

C. A potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and requires immediate attention as it may indicate hypokalemia, which can be a serious side effect of diuretic therapy.

D. A sodium level of 142 mEq/L is within the normal range and may not require immediate attention.

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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 stage pressure ulcer.

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Naxlex Comprehensive Predictor Exams

An advantage of delegation in client care is that:

Correct Answer is D

Explanation

The nurse notes that a diuretic is listed on the client's medication administration record (MAR). It is most important for the nurse to report to the physician a serum:

Correct Answer is C

Explanation

Which nursing action is most helpful in thinning a client's thick respiratory secretions?

A nurse doing discharge teaching for a client with severe cardiopulmonary disease recognizes a need for further explanation when the client states, "I:

The nurse recognizes that the five "rights" associated with delegation in nursing Include the right: (SELECT ALL THAT APPLY)

A client is diagnosed with chronic constipation. The nurse is given an order by the physician to administer a glycerin suppository. What abbreviation will be written in the physician's order for the administration route for the suppository?

The best way for the nurse to assess a client's level of dyspnea is to:

A nursing Instructor is observing a nursing student prepare and administer medications to adult clients. Which action by the nursing student requires intervention by the instructor?

The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that: