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","D"]

Explanation

A. Monitoring intake and output is important in assessing renal function and fluid balance.

B. Assessing the client for muscle weakness is crucial as hyperkalemia can lead to neuromuscular complications.

C. Encouraging intake of potassium-rich foods is contraindicated in hyperkalemia as it can further increase potassium levels.

D. Obtaining a physician's order for cardiac monitoring is a high priority as hyperkalemia can lead to cardiac dysrhythmias.

E. Diluting potassium elixir prior to IV administration is not relevant in this scenario.

A. Apply a sterile normal saline dressing B. Use sterile gloves to replace the protruding parts C. Administer IV antibiotics STAT D. Place the client in reverse Trendelenburg position

Correct Answer is A

Explanation

A. if a client's abdominal wound has eviscerated, the first intervention should be to apply a sterile normal saline dressing to the area and then seek immediate medical assistance.

B. Using sterile gloves to replace the protruding parts is not recommended since it can result in further damage of the organs.

C. Administering IV antibiotics may be indicated later but is not the first priority.

D. Placing the client in reverse Trendelenburg position is not the first priority and may not be appropriate for managing evisceration.

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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

A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the high priority Intervention(s) for this client is/are to: (SELECT ALL THAT APPLY)

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

Explanation

The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

The nurse misreads the electronic medication administration record (MAR) and administers twice the amount of antihypertensive medication that was ordered for the client. When realizing the mistake, the first action should be to:

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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?

The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client.Assuming that there are no skin problems, which is the preferred site for the injection?