Correct Answer: C

Rationale: Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.

Correct Answer: C

Rationale: Assess the apical pulse for a full minute: When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias. Assess the pedal pulses for a full minute: Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate. Assess the apical pulse with a Doppler device: A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation. Assess the pedal pulses with a Doppler device: Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.

Correct Answer: B

Rationale: SA Node: The SA (sinoatrial) node initiates electrical impulses and is responsible for atrial depolarization, which produces the P wave on an ECG. This makes it the correct answer. AV Node: The AV node is responsible for delaying electrical impulses before they pass to the ventricles, but it does not generate the P wave. It affects the PR interval rather than the P wave itself. Purkinje Fibers: The Purkinje fibers play a role in ventricular contraction (QRS complex), not in the formation of the P wave. Bundle of HIS: The Bundle of HIS transmits impulses to the ventricles and is involved in ventricular depolarization, not atrial activity. It is not responsible for the P wave.

Correct Answer: A

Rationale: Respirations: C4 injuries compromise the phrenic nerve, which controls the diaphragm. A high cervical spine injury can lead to respiratory failure, making airway and breathing the top priority. Pulse: While monitoring circulation is important, breathing takes priority in a C4 injury due to the risk of respiratory paralysis. Temperature: Temperature regulation may be affected due to autonomic dysfunction, but airway and breathing remain the priority. Blood Pressure: While spinal cord injuries can cause neurogenic shock (low BP, bradycardia), ensuring airway and breathing comes first.

Correct Answer: C

Rationale: Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.