Question 1

The nurse assesses several patients using the Braden Scale.Which patient will need the most intensive interventions?

Accepted Answer

The Braden Scale measures the risk of developing pressure ulcers, with lower scores indicating higher risk. A score of 6 is very low, suggesting the patient is at high risk and needs intensive interventions.

Question 2

The nurse assesses the patient's pressure ulcer after 2 weeks of ambulatory wound care and observes pink tissue at the base of the wound.Which intervention by the nurse is most appropriate?

Accepted Answer

Pink tissue at the base of the wound indicates granulation tissue, which is a sign of healing. A hydrocolloid dressing is appropriate as it maintains a moist environment conducive to healing.

Question 3

The patient requires prone positioning for a severe respiratory condition.Which areas are at risk for developing a pressure ulcer and require pillow bridging as a prevention strategy?

Accepted Answer

A

Question 4

Which rationale pertaining to a patient best justifies the suggestion by the nurse to use a support surface or special mattress?

Accepted Answer

Support surfaces or special mattresses are used to reduce the risks associated with immobility, such as pressure ulcers, by redistributing pressure and enhancing comfort.

Question 5

The student nurse a patient's pressure ulcer.Which assessment datum does the student use to support the identification of a stage 3 pressure ulcer?

Accepted Answer

Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia.

Question 6

A patient has a slight skin breakdown in the perianal area from incontinent stools.For which combination of therapies does the nurse obtain an order?

Accepted Answer

The answer of A patient has a slight skin breakdown...

Question 7

The patient is at risk for development of a pressure ulcer.Which problem related to the patient's iron deficiency anemia and smoking habit supports the nurse's decision to address the anemia for prevention of a pressure ulcer?

Accepted Answer

Iron deficiency anemia can lead to decreased oxygen-carrying capacity of the blood, resulting in decreased tissue perfusion. This can impair wound healing and increase the risk of pressure ulcers.

Question 8

The patient has a clean partial-thickness wound.Which dressing material should the nurse choose for dressing this ulcer?

Accepted Answer

The answer of The patient has a clean partial-thickness wound.Which...

Question 9

The nurse is caring for a patient with a small chronic pressure ulcer on the ankle.Which activity can the nurse delegate to nursing assistive personnel (NAP)?

Accepted Answer

Repositioning the patient is a task that can be delegated to nursing assistive personnel as it does not require clinical judgment or assessment skills.

Question 10

A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage 1 pressure injury.What datum about the area of concern will best help the nurse determine the correct staging assessment?

Accepted Answer

In patients with darkly pigmented skin, a stage 1 pressure injury may present as skin that is darker than the surrounding tissue, rather than the redness seen in lighter skin tones.

Question 11

The nurse observes a thick, dark brown covering over a large wound and needs to stage the wound.What action by the nurse is most appropriate?

Accepted Answer

The thick, dark brown covering is likely eschar, which needs to be removed or debrided before accurate staging of the wound can occur.

Question 12

A patient has a pressure injury with dry wound base.Which action by the nurse provides the most appropriate wound care?

Accepted Answer

Hydrogel dressings are appropriate for dry wound bases as they provide moisture, promoting healing. Optimal nutritional support is also crucial for wound healing.

Question 13

The patient's pressure ulcer needs packing and has a moderate-to-heavy amount of drainage.Which type of dressing should the wound care nurse use on the ulcer?

Accepted Answer

Calcium alginate dressings are highly absorbent and are suitable for wounds with moderate-to-heavy drainage, making them ideal for packing pressure ulcers with such drainage levels.

Question 14

The nurse is assessing a newly admitted patient with a pressure ulcer on the hip.Which clinical indicator does the nurse use to assess a stage 2 pressure ulcer?

Accepted Answer

A stage 2 pressure ulcer is characterized by partial-thickness skin loss with exposed dermis, which often presents as a superficial blister or shallow open ulcer.

Question 15

The nurse assesses the patient's pressure ulcer and notes tissue maceration around the wound.Which action does the nurse take to address this issue?

Accepted Answer

Using a skin barrier helps protect the surrounding skin from moisture and further maceration, addressing the issue directly.

Question 16

The nurse is caring for four patients at risk for impaired skin integrity.Which patient requires the most frequent assessment and possible intervention?

Accepted Answer

The malnourished, bedridden patient with a nasogastric tube is at the highest risk for impaired skin integrity due to immobility, poor nutrition, and potential pressure ulcers, requiring frequent assessment and intervention.

Question 17

The patient's sacrum has nonblanching redness on Monday.On Wednesday the nurse determines that the pressure ulcer on the patient's sacrum is stage 2 despite skin care, including an air-filled mattress overlay.Which is the best nursing intervention to implement now?

Accepted Answer

Reassessing the patient's need for a different support surface or bed is crucial to prevent further deterioration of the pressure ulcer and promote healing.

Question 18

The nurse uses the Braden Scale to assess the patient's pressure ulcer risk.Which patient score mandates that the nurse implement aggressive prevention measures because of being at high risk for skin breakdown?

Accepted Answer

A score of less than 9 on the Braden Scale indicates a very high risk for pressure ulcers, necessitating aggressive prevention measures.

Question 19

The nurse is positioning a patient at risk for development of a pressure injury.Which potential pressure point(s) does the nurse relieve by assisting the patient to a side-lying position?

Accepted Answer

The answer of The nurse is positioning a patient at...

Question 20

The nurse admits a patient to the surgical unit and determines that the patient's Braden Scale score is 18.Which does the nurse include in the patient's initial plan of care?

Accepted Answer

A Braden Scale score of 18 indicates a mild risk for pressure ulcers. Maintaining the head of the bed at approximately 30 degrees helps reduce pressure on the sacrum and other bony prominences, which is important for preventing pressure ulcers.

Quiz 26: Pressure Injury Prevention and Care