A Stage III pressure ulcer shows
A. full-thickness skin loss extending to the muscle, tendon, or bone.
B. a highly defined area or red, shiny, intact skin.
C. full-thickness skin loss with damage of subcutaneous tissue.
D. partial-thickness skin loss with an abrasion or blistered surface.
Answer: C
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The nurse is caring for a client complaining of a backache and administers ibuprofen. The client asks the nurse how the medication will help the pain. The nurse understands that ibuprofen's effect occurs during which phase of nocioception?
1. Transduction 2. Transmission 3. Perception 4. Modulation
A provider has ordered captopril [Capoten] for a patient who has hypertension. The patient reports a history of swelling of the tongue and lips after taking enalapril [Vasotec] in the past. Which action by the nurse is correct?
a. Administer the captopril and monitor for adverse effects. b. Hold the dose and notify the provider. c. Request an order to administer fosinopril instead of captopril. d. Reassure the patient that this is not a se-rious side effect.
The nurse is preparing to flush a PICC line. The protocol specifies using 50 units of heparin. Available is a multidose vial containing heparin, 10 units/mL. Which syringe does the nurse use to draw up and administer the heparin?
What will be an ideal response?
The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?
1. "I need to get RhoGAM so I don't have problems with my next pregnancy." 2. "Because my baby is Rh-positive, I don't need RhoGAM." 3. "If my baby had the same blood type I do, it might cause complications." 4. "Before my next pregnancy, I will need to have a RhoGAM shot."