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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. AV Node: The AV node is responsible for delaying electrical impulses before they pass to the ventricles, but it does not generate the P wave. It affects the PR interval rather than the P wave itself.

B. SA Node: The SA (sinoatrial) node initiates electrical impulses and is responsible for atrial depolarization, which produces the P wave on an ECG. This makes it the correct answer.

C. Purkinje Fibers: The Purkinje fibers play a role in ventricular contraction (QRS complex), not in the formation of the P wave.

D. Bundle of HIS: The Bundle of HIS transmits impulses to the ventricles and is involved in ventricular depolarization, not atrial activity. It is not responsible for the P wave.

A. You will need to use a stethoscope properly. B. You can move your arm during the reading C. You can apply the cuff in any manner D. You will need to recalibrate the machine

Correct Answer is D

Explanation

A. You will need to use a stethoscope properly. A portable electronic blood pressure device is automatic and does not require the use of a stethoscope. The device detects oscillations in arterial pressure to provide a reading.

B. You can move your arm during the reading. Movement during the reading can interfere with accuracy and produce incorrect results. The patient should keep the arm still and at heart level.

C. You can apply the cuff in any manner. The cuff must be applied correctly—snug but not too tight, with the lower edge about 1 inch above the antecubital fossa, and the bladder of the cuff positioned over the artery—to ensure accurate readings.

D. You will need to recalibrate the machine. Electronic blood pressure devices require periodic recalibration to maintain accuracy. The patient should follow the manufacturer’s guidelines for recalibration and compare readings with a manual blood pressure check at clinic visits.

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Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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