hesi week 9

Which term should the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence caused by pressure?

Callus

A nurse assesses four different clients with pressure ulcers. Which client is suspected of having an unstageable ulcer?

Client B, Base of ulcer covered by slough

A nurse is assessing a newly admitted client with the pressure ulcer indicated in the picture. Which pressure ulcer stage should the nurse document on the admission history and physical?

Stage 2 (opened skin) (shallow)

Which key feature is most likely associated with the pressure ulcer stage shown in the figure?

loss of full thickness of skin

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?

Frequent repositioning of client

A primary healthcare provider is treating the red-color wound of a client caused by pressure ulcers. Which dressings are beneficial for wound recovery? Select all that apply.

Hydrocolloid dressings Transparent film dressings Telfa dressings with antibiotic ointment

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

With the help of another staff member, use a drawsheet when lifting the client in bed.

The nurse is assessing four clients with foot disorders. Which client is instructed to use bunion pads to relieve pressure on the bursal sac?

Client A

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer?

D (sacrum)

What is the etiology for the development of pressure ulcers in an 80-year-old client?

Decreased subcutaneous fat

The nurse instructs a client about the safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which action of the client does the nurse expect is the reason for the client's condition? Select all that apply.

Massaging the reddened skin areas Using donut-shaped pillows for pressure relief

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply.

Anorexia Hemiplegia History of diabetes Urinary incontinence

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing?

Vitamin C is required for collagen production by fibroblasts.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?

Incontinence and inability to move independently

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

Inspecting the skin daily

Which practice would be suitable in the prevention of a pressure ulcer?

Keeping the client's skin directly off plastic surfaces

A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment device has been prescribed to hasten wound healing. Which nursing action is most appropriate when caring for this client?

Replace the wound sponge every 48 hours.

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of nonintact skin

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer?

The client should have been turned regularly.

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action?

Turn and reposition the client every 2 hours.

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up?

"I should apply powders or talc on a perineum wound."

A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching?

"I should not worry about what the client eats."

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply.

"I should use pressure-relieving pads." "I should place pillows between two bony surfaces." "I should keep my heels off the bed surface using a bed pillow under the ankles."

The nurse instructs self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer. Which statement of the client shows ineffective learning?

"I will apply powders and talc on the perineum."

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply.

"I will elevate the head of the client's bed to 30 degrees." "I will instruct the client to take baths in lukewarm water." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

Which disorder of the foot is caused by continual pressure over bony prominences?

Corn

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer?

Stage IV

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?

Unstageable