A patient's pressure ulcer is 3 cm in diameter and 1 cm deep and has tunneling on the left side. The ulcer holds 17 mL of normal saline and has no visible fascia or bone in the ulcer. What pressure ulcer stage should the nurse document?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: C
A stage 3 ulcer has full-thickness skin loss, which extends to the subcutaneous tissue but not fascia. The ulcer looks like a deep crater and may have undermining of adjacent tissue. A. Skin is still intact in stage 1. B. Stage 2 is shallow. D. Stage 4 has damage to muscle and bone.
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A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom?
a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets.
A client is scheduled for diagnostic skin testing in 1 week. What should the nurse be sure to instruct the client prior to the scheduled appointment?
A) Do not take prescribed or over-the-counter antihistamines or cold preparations for at least 72 hours before testing. B) Do not take antihypertensive medications the morning of the scheduled skin testing. C) Do not take nonsteroidal anti-inflammatory (NSAID) medications for 1 week prior to the scheduled skin testing. D) Prior to having the skin test, have the client take an over-the-counter histamine prophylactically for any possible reaction that could cause anaphylaxis.
A high school student who is on the wrestling team has been trying to drop weight before the next match and is now experiencing swollen fingers and a headache. Which laboratory finding should the nurse expect for this client?
a. Sodium 127 mEq/ L b. Potassium 5.5 mEq/ L c. Respiratory rate is 10 per minute d. Temperature 97. 2 degrees Fahrenheit
A resident is dying. The doctor wrote a "Do Not Resuscitate" order. You do not agree with the order. Which is correct?
a. You can start CPR if necessary. b. You do not have to follow the order. c. You must follow the order. d. You do not have to care for the person.