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 ["A","B"]

Explanation

A. Renal impairment can affect drug metabolism and elimination, requiring dosage adjustments or different medication choices.

B. Liver failure can impair drug metabolism and clearance, necessitating dosage adjustments or alternative medications.

C. Hearing impairment does not directly affect pharmacokinetics.

D. Muscle sprain does not directly affect pharmacokinetics.

E. Vaginal infection does not directly affect pharmacokinetics.

A. Encourage eating potassium rich foods B. Monitor intake and output C. Restrict sodium in the diet D. Monitor vital signs E. Decrease water intake

Correct Answer is ["B","C","D"]

Explanation

A. Encouraging potassium-rich foods is not directly related to the treatment of hypernatremia.

B. Monitoring intake and output is important to assess fluid balance, especially in clients with hypernatremia.

C. Restricting sodium in the diet is essential to prevent further elevation of sodium levels in hypernatremia.

D. Monitoring vital signs helps assess the client's overall condition and response to treatment.

E. Decreasing water intake is not advisable in hypernatremia, since one of the causes of hypernatremia is dehydration. Therefore, limiting water intake may worsen the hypernatremia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering medications to a group of clients. Which client(s) warrant(s) the nurse's special attention when considering pharmacokinetics? The client(s) who has (have) a medical diagnosis of: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B"]

Explanation

A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

The nurse knows that teaching about the use of the incentive spirometer is effective when the client seals the lips around the mouthpiece and:

A group that has transformed itself from a collection of individuals into a productive, problem-solving, highly functioning team would be functioning in which stage of group development?

The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

The nurse must give a client an intramuscular injection of a medication which is very Irritating to the subcutaneous tissues. To attempt to minimize client discomfort, which action should the nurse take?

The nurse receives the following order: "Ferrous sulfate 325 mg four times a day PO. Give on empty stomach." Even before researching, the nurse guesses that this is because the medication:

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?

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

At which site on the diagram would the nurse give an Intramuscular injection into the vastus lateralis?