A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
D
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
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MC The pressure in the blood pressure cuff is deflated
A. Quickly at 5 points or mm Hg/second. B. Slowly at 2 points or mm Hg/second. C. Gradually at 2 to 4 points or mm Hg/second. D. At a rate that does not exceed 5 points or mm Hg/second.
The wife of an older man who has diabetes mellitus brings him to primary care. He has severe bilateral infections forming black rings around each ankle. He tells the nurse it is caused by tight shoes
Which intervention should the nurse implement first to investigate this individual's health care regimen? a. Examine his health insurance coverage. b. Question the man without the wife present. c. Consult with social services about neglect. d. Analyze his glycosylated hemoglobin lev-el.
The nurse is preparing to discharge a client with chronic kidney disease. The nurse is teaching the client and family about administering calcium acetate tablets by mouth with each meal at home
Which explanation about this medication is the most appropriate? A) "The calcium acetate will lower your serum phosphate levels." B) "The calcium acetate helps to neutralize your gastric acids." C) "The calcium acetate will help to stimulate your appetite." D) "The calcium acetate will decrease your serum creatinine levels."
____________________ is the inability to speak or understand.
Fill in the blank(s) with the appropriate word(s).