NCLEX-PN

46. The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern? A.​ The client was bathed and skin was assessed head-to-toe at 0900 with no abnormal findings. B.​ The client’s indwelling urinary catheter was last changed 5 days ago.

C.​ The client’s PEG tube was changed 6 months ago. D.​ The client was repositioned on his right side at 1100. Correct Response: D

Explanation : The correct answer is (D) . The LPN should be particularly concerned about the statement that the comatose client was repositioned on his right side at 1100. Given the bedridden status of the client, regular repositioning every two hours is crucial to prevent the development of pressure ulcers and skin breakdown. Failing to adhere to this recommended repositioning schedule can lead to serious complications for immobilized clients, making it a matter of immediate concern. In contrast, the report of the client being bathed and the skin being assessed at 0900 with no abnormal findings (A) is a positive aspect of the report, indicating routine skin care. While the client's indwelling urinary catheter not being changed for 5 days (B) raises infection risk concerns, it is not as time-sensitive as the failure to reposition the comatose client at the recommended intervals. Additionally, the report of the PEG tube being changed 6 months ago (C) is not an immediate concern during this shift. In summary, the LPN should prioritize addressing the lack of timely repositioning to mitigate the risk of skin breakdown for the bedridden client. (See Implementing Strategies for Skin Integrity Maintenance and Prevention of Skin Breakdown ) 47. While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer? A.​ Stage I Explanation :The correct answer is (D) Stage II. While repositioning the client, the LPN observes a shallow, open ulcer on the sacrum with partial-thickness skin loss, classifying it as Stage II in the wound classification system. Stage II denotes damage to both the epidermis and dermis, indicating that the skin is not intact. This stage is characterized by partial-thickness skin loss, aligning with the observed features of the ulcer. The LPN appropriately rules out other stages: (A) Stage I, characterized by intact skin with non-blanchable redness; (B) Stage III, involving full-thickness skin loss extending into subcutaneous tissue; and (C) Stage IV, representing the most severe form with damage to deeper structures. The LPN's recognition of the ulcer's characteristics aligns with the appropriate wound classification, ensuring accurate assessment and subsequent care planning for the client. (See Implementing Strategies for Skin Integrity Maintenance and Prevention of Skin Breakdown ) B.​ Stage III C.​ Stage IV D.​ Stage II Correct Response: D

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