While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Stage II pressure ulcer

Stage IV pressure ulcer

Stage I pressure ulcer

Stage III pressure ulcer

Answer and Explanation

The Correct Answer is A

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

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Correct Answer is B

Explanation

When educating a preoperative client on how to eﬀectively deep breathe, the nurse should instruct the client to make each breath deep enough to move the bottom ribs. This helps to ensure that the client is taking deep breaths and fully expanding their lungs. The other options (Breathe in through the mouth and out through the nose, Practice deep breathing at least once each week, and Breathe through the mouth when you inhale and exhale) are not accurate instructions for eﬀective deep breathing.

A. Instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose. B. Instruct the client to inhale normally and then place the lips securely around the mouthpiece. C. Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible. D. When the client cannot inhale anymore, the client should hold his breath and count to 10.

Correct Answer is A

Explanation

When providing education to a postoperative client on how to use an incentive spirometer, an accurate step that should be included in the education plan is to instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose ¹⁴. This helps the client to take deep breaths and fully expand their lungs. The other options (Instruct the client to inhale normally and then place the lips securely around the mouthpiece, Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible, and When the client cannot inhale anymore, the client should hold his breath and count to 10) are not accurate steps that should be included in the education plan.

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While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a preoperative client on how to eﬀectively deep breathe. Which instruction would be included?

Correct Answer is B

Explanation

A nurse is providing education to a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the education plan?

Correct Answer is A

Explanation

A nurse is taking care of an adult client who throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying?

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

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