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 D

Explanation

A. "Your disease often makes patients lose mental status." While severe hypoxia can cause confusion, this response does not address the reason for clubbing and lacks therapeutic communication.

B. "Your disease will be helped if you pursed-lip breathe." Pursed-lip breathing helps with air trapping and exhalation in COPD, but it does not explain clubbing of the fingers.

C. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." COPD primarily affects oxygen exchange in the lungs, not necessarily blood pumping from the heart. Clubbing is due to chronic hypoxia, not poor cardiac output.

D. "Your disease doesn't send enough oxygen to your fingertips." Chronic hypoxia in COPD leads to increased capillary growth and tissue changes, resulting in clubbing of the fingers. This response is accurate and appropriately explains the cause.

A. Shortness of breath B. Adequate dietary intake C. Decrease level of consciousness D. Muscular Pain

Correct Answer is C

Explanation

A. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development.

B. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor.

C. Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort.

D. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.

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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?

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Naxlex Comprehensive Predictor Exams

A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is the most therapeutic?

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Correct Answer is C

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