Deck 25: Pressure Ulcers

Question 1

One outcome for a patient on bed rest is that the patient has intact skin within 2 weeks.Which rationale pertaining to the patient best justifies the suggestion by the nurse to use a support surface or special mattress?

A) It eliminates pain and discomfort.
B) It prevents joint contractures.
C) It eliminates the need for turning.
D) It reduces risks of immobility.

Answer 1

It reduces risks of immobility.

Question 2

Patients with a dry wound base have a better chance of wound healing if certain approaches are used.Nursing care would be correctly focused on the maximum outcome if which interventions were used?

A) Using dry gauze dressings and a liquid antimicrobial into the wound
B) Optimal nutritional support and the use of hydrogel dressings
C) Bathing frequently with soap and the use of transparent film dressings
D) Using nonstick pads and enzymatic débriding agents

Answer 2

Optimal nutritional support and the use of hydrogel dressings

Question 3

The nurse admits the 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?

A) Using moisturizing lotion to massage the sacrum
B) Assisting the patient to turn and reposition every 4 hours
C) Keeping the skin clean and dry with frequent bathing
D) Maintaining the head of the bed at approximately 30 degrees

Answer 3

Maintaining the head of the bed at approximately 30 degrees

Question 4

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

A) Removing this covering with a sterile forceps and scissors
B) Filling the base of the patient's ulcer with a silicone lotion
C) Placing a hydrocolloid dressing directly over the tannish-brown covering
D) Deferring staging until the tannish-brown covering has been removed

Question 5

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?

A) Eliminates dead space
B) Uses a skin barrier
C) Applies a foam dressing
D) Obtains a wound culture

Question 6

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?

A) Ears and toes
B) Nose and elbows
C) Occipital area and knees
D) Sacrum and coccyx

Question 7

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

A) Symphysis pubis
B) Ischial tuberosities
C) Greater trochanters
D) Occipital prominence

Question 8

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

A) The skin will be slightly broken.
B) The skin color is darker than surrounding tissues.
C) The tissue is the same temperature as surrounding tissues.
D) The skin blanches easily.

Question 9

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

A) Diapers and a moisture barrier ointment
B) Hydrogen peroxide and povidone-iodine
C) Fecal incontinence bag and a protective barrier paste
D) Alginate and transparent film dressings

Question 10

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

A) Strip packing
B) Nonstick pads
C) Transparent film
D) Alginate dressings

Question 11

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)?

A) Measure the wound for length, width, and depth.
B) Reposition the patient at least every 2 hours.
C) Ask the patient to rate the pain during the dressing change.
D) Examine the wound bed for the type and amount of tissue.

Question 12

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 II despite skin care,including an air-filled mattress overlay.Which is the best nursing intervention to implement?

A) Document the extreme progression of the patient's pressure ulcer.
B) Collaborate with the healthcare provider for physical therapy.
C) Reassess the patient's need for a different support surface or bed.
D) Increase the frequency of bathing and linen changes as needed.

Question 13

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 II pressure ulcer?

A) Deep, open crater
B) Persistent redness
C) Boggy consistency
D) Superficial blistering

Question 14

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 should the nurse implement?

A) Refer the patient to a dietitian to improve nutrition.
B) Alter the wound care to include a débriding agent.
C) Collaborate with the healthcare provider for wound culture.
D) Recommend a hydrocolloid wound dressing.

Question 15

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

A) A malnourished, homeless patient with a nasogastric tube who is bedridden
B) A college football player with bilateral long leg casts after a motorcycle accident
C) An elderly female ambulating after hip replacement surgery
D) A school-age child recovering from a tonsillectomy and adenoidectomy

Question 16

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?

A) Decreased tissue perfusion
B) Decreased mobility impairment
C) Increased skin moisture
D) Increased level of consciousness

Question 17

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?

A) Less than 9
B) 15 to 18
C) 19
D) 23

Question 18

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?

A) Foam
B) Hydrogel
C) Impregnated gauze
D) Alginate

Question 19

The nurse assesses a patient with a pressure ulcer.Which assessment datum does the nurse use to support the identification of a stage III pressure ulcer?

A) Nonblanching and reddened areas of intact skin
B) Extensive destruction of the skin and muscle
C) Full-thickness skin loss from the surface down to the bone
D) Full-thickness skin loss from the surface down to the fascia

Question 20

The nurse assesses a patient using the Braden scale.A patient having a majority of which number indicates being at great risk for pressure sores?

A) 1
B) 2
C) 3
D) 4

Question 21

The nurse is planning care for her patients and is concerned about skin breakdown and delayed wound healing.Which of the following patients are likely to be at a higher risk for wound healing should they develop a pressure ulcer? (Select all that apply.)

A) An elderly female patient with mobility issues
B) A young diabetic patient in traction and on bed rest
C) A teenager receiving chemotherapy
D) An elderly man with stage IV congestive heart failure
E) A middle-aged woman with lupus who is having back surgery but is ambulatory

Question 22

The nurse is concerned about device-related pressure ulcers in her patients.Which of the following interventions should she take?(Select all that apply.)

A) Perform frequent skin assessment under devices and tubes.
B) Assess for edema in the skin underlying a tube.
C) Rotate tubes to different positions to relieve pressure.
D) Implement pressure ulcer care bundles.
E) Do not remove the adhesive tape until it is time to remove the device.

Question 23

2. The rubbing of the tissue against a surface is called ______; it abrades the top layer of skin (epidermis),which makes tissue susceptible to pressure injury.

Question 24

1. Poor _____ ___________ decreases the patient's ability to feel the sensation of pressure or discomfort.

Question 25

3. A parallel force that stretches tissue and blood vessels is called _______.

Question 26

The nurse is delegating care related to her patients to the NAP.Which of the following indicates the nurse is appropriately delegating tasks related to pressure ulcer care? (Select all that apply.)

A) The nurse asks the NAP to report any redness in the patient's skin.
B) The nurse explains to the NAP that the patient will need to be repositioned every 2 hours.
C) The nurse asks the NAP to assess the patient's risk factors for skin breakdown.
D) The nurse explains to the NAP which positions the patient should be repositioned in.
E) The nurse asks the NAP to record the patient's nutritional intake.