Deck 26: Pressure Injury Prevention and Care

Question 1

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

A) Score of 1
B) Score of 6
C) Score of 14
D) Score of 17

Answer 1

Score of 6

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?

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

Answer 2

Recommend a hydrocolloid wound dressing.

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?

A) Chin and knees
B) Nose and elbows
C) Occipital and parietal areas
D) Sacrum and coccyx

Answer 3

Chin and knees

Question 4

Which rationale pertaining to a 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.

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?

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 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?

A) Moisture barrier ointment
B) Hydrogen peroxide for cleansing
C) Fecal incontinence bag
D) Calcium alginate dressings

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?

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

Question 8

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

A) Moist gauze
B) Foam dressings
C) Transparent film
D) Alginate dressings

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)?

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 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?

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 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?

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 brown covering has been removed

Question 12

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

A) Using dry gauze dressings and a liquid antimicrobial on 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

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?

A) Foam
B) Hydrogel
C) Impregnated gauze
D) Calcium alginate

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?

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

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?

A) Measures the wound bed.
B) Uses a skin barrier.
C) Applies a foam dressing.
D) Obtains a wound culture.

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?

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 older adult ambulating after hip replacement surgery
D) A school-age child recovering from a tonsillectomy and adenoidectomy

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?

A) Document the extreme progression of the patient's pressure ulcer.
B) Collaborate with the health care 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 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?

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

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?

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

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?

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

Question 21

The nurse assesses the patient's skin.What does the nurse document for this injury?

A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Incontinence dermatitis
D) Unstageable injury

Question 22

The nurse is planning care for a group of 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 impaired wound healing should they develop a pressure ulcer? (Select all that apply.)

A) An elderly patient with mobility issues
B) A young diabetic patient in traction and on bed rest
C) A teenager receiving chemotherapy
D) An elderly person with stage IV congestive heart failure
E) A middle-aged patient with frequent headaches having back surgery

Question 23

The student nurse is caring for a patient with a continuous bedside pressure mapping device and asks the faculty to explain the purpose of this intervention.What response by the faculty is best?

A) Reduces the need to turn the patient frequently.
B) Provides real-time data regarding pressure on patient surfaces.
C) The alarm alerts the staff when the patient tries to exit the bed.
D) They adjust the flow of air in specialty beds.

Question 24

A nurse is caring for four patients who all have a Braden Scale score of 13.What intervention by the nurse is most appropriate?

A) Delegate turning all the patients at the same time.
B) Consult the wound-ostomy-continence nurse.
C) Assess the factors that increase each patient's risk.
D) Request specialty beds or overlays for each patient.

Question 25

The nurse is concerned about device-related pressure ulcers in a group of patients.Which of the following interventions are most appropriate to reduce this risk? (Select all that apply.)

A) Perform frequent skin assessment under devices and tubes.
B) Remove the device periodically to protect the skin.
C) Rotate tubes to different positions to relieve pressure.
D) Implement pressure injury care bundles.
E) Do not remove the adhesive tape until it is time to remove the device.