Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?
Disposable measuring tape
Cotton-tipped applicator
Natural light
Sterile gloves
The Correct Answer is C
A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.
B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.
C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.
D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing changes in body temperature. The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions).
B. Being aware of the usual values for the patient. While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values.
C. Obtaining temperature measurements at ordered frequency. This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment.
D. Using an appropriate route and device. While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.
Correct Answer is C
Explanation
A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.
B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.
C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.
D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.
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