Deck 39: Pressure Injury Prevention and Care

Question 1

The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound.How would the nurse classify this ulcer?

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

Answer 1

Wound that cannot be staged

Question 2

In a patient with a stage II pressure ulcer,the nurse describes the wound as:

A)superficial blistering.
B)nonblanchable redness.
C)loss of skin without bone exposure.
D)loss of skin with exposed muscle.

Answer 2

superficial blistering.

Question 3

Patients are at risk for developing pressure ulcers on which areas of the body? (Select all that apply. )

A)Coccyx
B)Nares
C)Ears
D)Genitalia

Answer 3

Coccyx
Nares
Ears
Genitalia

Question 4

A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?

A)Wound needs debridement
B)The presence of significant infection
C)Colonization by bacteria
D)Movement toward healing

Question 5

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 6

Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to:

A)16.
B)18.
C)20.
D)24.

Question 7

In a long-term care agency,how often should the nurse reassess a patient for risk of a pressure ulcer?

A)Every 1 to 2 days
B)Every time the nurse sees the patient
C)Weekly for the first few weeks of stay
D)Monthly for the first 4 months of stay

Question 8

After teaching a home caregiver how to manage 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 9

The nurse is aware that 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)only in bed bound patients.
D)in as little as 90 minutes.

Question 10

When skin layers adhere to the linens and deeper tissue layer move downward,________ damage occurs.

Question 11

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 feels 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 12

When evaluating a patient,the 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 patient for systemic signs and symptoms.

Question 13

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

A)Edema in the sacrum
B)Skin texture
C)Skin temperature
D)Pallor or mottling of the skin

Question 14

The patient with a nasogastric (NG)tube in place may experience skin breakdown:

A)in the nose.
B)on the tongue.
C)behind the ears.
D)around the lips.

Question 15

The nurse knows that which of the following factors contribute to the development of pressure ulcers? (Select all that apply. )

A)Friction and shear
B)Immobility
C)Poor nutrition
D)Moisture and ammonia
E)Uncontrolled pain

Question 16

A patient with anemia is at risk for developing pressure ulcers as a result of which of the following?

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

Question 17

The nurse is planning 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)Maintaining moisture in the wound

Question 18

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

Question 19

The nurse is caring for four patients during a shift.Which of the following patients 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