The nurse assessing a patient with a sacral decubitus finds that the ulcer extends into the muscle and bone. In which stage is this ulcer?
A) I
B) II
C) III
D) IV
Ans: D
Feedback: Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue; with this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.
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Graduates from approved schools of nursing cannot sign their charting as registered nurses (RNs) until they:
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A student is rushed to the school health clinic because of a nosebleed. The towel he is holding is saturated with blood, and when he removes it, the bleeding continues in large quantities and is deep red
What is most important to determine initially? A) Whether the classroom environment is particularly dry B) History of sinusitis symptoms or exposure C) History of trauma before the onset of bleeding D) Family history of nosebleeds