Deck 18: Pressure Ulcer Care

Question 1

Pressure ulcers can occur: (Select all that apply.)

A) From any position that causes soft tissue compression
B) Because of lack of blood flow (ischemia)
C) If pressure lasts longer than 90 minutes
D) In as little as 90 minutes

Answer 1

From any position that causes soft tissue compression
Because of lack of blood flow (ischemia)
In as little as 90 minutes

Question 2

Factors that contribute to the development of pressure ulcers include: (Select all that apply.)

A) Friction and shear
B) Immobility
C) Poor nutrition
D) Moisture and ammonia
E) None of above

Answer 2

Friction and shear
Immobility
Poor nutrition
Moisture and ammonia

Question 3

A nurse classifies a pressure ulcer according to the color of the wound bed.A red wound has:

A) Necrotic tissue
B) Significant infection
C) Slough
D) Granulation tissue

Answer 3

Granulation tissue

Question 4

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient,the nurse who is performing the assessment should pay particular attention to:

A) Edema
B) Massaging any reddened area
C) Touching the skin
D) Pallor or mottling of the skin

Question 5

The nurse has been caring for a patient with a stage IV ulcer.The ulcer has been steadily improving and now almost is healed.The nurse,at this point,can classify the ulcer as a:

A) Stage III pressure ulcer
B) Stage II pressure ulcer
C) Healing stage IV pressure ulcer
D) Stage I pressure ulcer

Question 6

Pressure ulcers can occur in which area of the body? (Select all that apply.)

A) Coccyx
B) Nares
C) Ears
D) Genitalia
E) None of above

Question 7

Aggressive prevention measures should be implemented for a client in the general population with a pressure ulcer risk on the Braden Scale of:

A) Less than or equal to 16
B) Less than or equal to 18
C) Less than or equal to 20
D) Less than or equal to 24

Question 8

When evaluating a client,a nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated.The nurse should:

A) Obtain a wound culture
B) Apply pressure-reducing devices
C) Use dressings with increased moisture absorption
D) Monitor the client for systemic signs and symptoms

Question 9

Any tension that stretches the skin during tuning or moving in bed is known as ______________.

Question 10

After teaching a home caregiver how to mange a pressure ulcer,the nurse realizes that further education is needed when the caregiver says:

A) "I will be sure to reposition her frequently and keep her off of the pressure ulcer."
B) "I will wash the pressure ulcer with saline and report any changes in the drainage."
C) "I know that a thick, black covering will protect the pressure ulcer from getting worse."
D) "I will let you know if the pressure ulcer starts to smell rotten."

Question 11

The nurse is planning to care for her patient,who has a stage II pressure ulcer.Care should include which of the following? (Select all that apply.)

A) A heat lamp to dry the wound
B) Application of topical antibiotics
C) Nutritional assessment
D) Maintenance of a moist wound environment

Question 12

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site does feel cooler than the areas immediately around the site.The nurse recognizes that this patient has developed:

A) A stage I pressure ulcer
B) A stage II pressure ulcer
C) An unstageable pressure ulcer
D) Deep tissue injury

Question 13

The removal of devitalized tissue in a wound is known as ______________.

Question 14

The patient is admitted with an open pressure ulcer with necrotic tissue covering the base.The nurse would classify this ulcer as a:

A) Stage III pressure ulcer
B) Stage IV ulcer
C) Wound cannot be staged
D) Stage II pressure ulcer

Question 15

The client with a nasogastric (NG)tube in place may experience skin breakdown at the:

A) Nose
B) Tongue
C) Area behind the ears
D) Area around the lips

Question 16

The nurse is caring for four patients on this shift.Who is at greatest risk for developing a pressure ulcer?

A) The patient who is bedridden, but who turns himself randomly
B) The patient whose Braden Scale score is 8
C) The patient who can ambulate to the bathroom independently
D) The patient whose Braden Scale score is 18

Question 17

A nurse assesses a stage II pressure ulcer as:

A) Superficial blistering
B) Nonblanchable redness
C) Loss of skin but without bone exposure
D) Loss of skin with exposed muscle

Question 18

A _______________ is a localized injury to the skin and/or underlying tissue,usually over a bony prominence,as a result of pressure,or pressure in combination with shear and/or friction.

Question 19

In a long-term care facility,reassessment of pressure ulcer risk is conducted:

A) Every 24 to 48 hours
B) Every time the nurse sees the client
C) Weekly for the first few weeks of stay
D) Monthly for the first 4 weeks of stay

Question 20

Anemia predisposes a client to pressure ulcers as a result of:

A) Increased sedation
B) Edematous tissues
C) Reduced tensile strength
D) Diminished oxygen to the tissues