NUR 113 Pressure Injury

The nurse receives hand-off report on a group of patients. Which patient is the highest risk for developing pressure injury? Select all that apply.

-A young adult who is a quadriplegic -An older adult who is bedridden and diaphoretic -A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool -A middle-aged adult with a Braden scale score of 7

Upon admission, the nurse knows that all patients must be assessed using the Braden Scale to evaluate the patient's risk for skin breakdown. Which of the following areas are included when assessing the patient using the Braden Scale? Select all that apply.

-Activity -Nutrition -Mobility

The nurse is reviewing the admission laboratory results for Louanne. Which of these laboratory findings are indicative of inflammation or infection?

-C-reactive protein (CRP) elevation -Erythrocyte sedimentation rate (ESR) elevation -White blood cell (WBC) elevation

What clients are at risk for pressure injury? Select all that apply.

-Clients with advanced age -Clients with malnutrition -Clients with urinary or fecal incontinence -Clients with dehydration

The nurse is caring for a patient at risk for skin breakdown. Which nursing interventions are appropriate to implement to minimize the effects of injury? Select all that apply.

-Use a draw sheet when moving the patient. -Minimize the amount of time the patient is in one position.

The nurse is caring for a client with a stage IV pressure injury on the coccyx. The nurse advises the client to increase which types of foods in the diet to assist in the healing process?

Meat and dairy (protein)

The nurse is caring for a bedbound patient with a pressure injury of the coccyx and a Braden score of 9. Which nursing action is the priority?

Position the head of the bed less than 30°.

The nurse is explaining to the student nurse the difference between undermining and tunneling. How should the nurse explain the two terms?

"Undermining is the destruction of tissue under the wound edges and tunneling is the development of a passageway under the skin's surface."

Despite the nurse's attempts to keep Louanne's heels away from the pressure of the mattress, she continues to kick the pillow out from under her legs. She tells the nurse "It doesn't hurt me, I don't see what the big deal is." How should the nurse respond?

"When your heels rest on the mattress, the continued pressure to the site creates injury."

Which point regarding surface swab culture for the identification and treatment of a wound infection indicates a need for better understanding?

"It is considered the gold standard in identifying wound pathogens."

Which skin condition should the nurse document as pressure injury stage II?

4

The nurse is admitting a client with a stage III pressure injury. Which serum lab values would the nurse expect to be drawn on the client during the hospital stay?

C-reactive protein and erythrocyte sedimentation rate

Louanne is 70 years old and lives with her husband of 52 years in a small rural community. Louanne was diagnosed with diabetes 5 years ago and the disease is poorly controlled. She presented to the office today with a deep red bruise on the heel of her foot that doesn't seem to be healing. She tells the provider that "I think something bit me." The provider removes Louanne's shoe and sees an area the size of a half dollar on the heel of her foot that is bright read and does not blanch. The provider notes that the shoes Louanne is wearing are very tight and too small for her foot. What type of injury is Louanne demonstrating?

Stage 1 pressure injury

The provider encourages Louanne to wear different shoes and return to the clinic in a week. When she returns, she has a low-grade fever and the heel has darkened in color. The red area now has a quarter-sized serum-filled blister. Louanne says "I tried some other shoes but they were not comfortable, so I went back to these." What stage pressure ulcer is now present?

Stage 2 pressure injury

A few days later, the nurse performs a focused assessment and identifies that Louanne's pressure injury is now full thickness. There is some bone showing. There is eschar on the edges of the site along with some tunneling. What stage injury should the nurse document?

Stage 4 pressure injury

The nurse is caring for a bedbound patient with a pressure injury of the coccyx and a Braden score of 6 out of 23. What does this indicate?

The patient is at a high risk for alteration in skin integrity.

Louanne's Braden Scale score is an 11. What conclusions can the nurse make?

The risk is high and referrals are needed for therapy services and wound care.

Louanne struggles to maintain a nutritious diet. What should the nurse encourage during the hospital stay for better wound healing?

protein

A nurse is assessing a patient's skin and notes a 1 cm shallow crater on the coccyx. The site is painful to palpation. How should the nurse document the stage of this wound?

stage II

In which stage does a pressure injury show a partial loss in the thickness of the dermis?

stage II

The nurse is assessing a pressure ulcer with full thickness tissue loss, visible subcutaneous fat with no bone, muscle, or tendons exposed. Slough is present, but does not obscure the depth of tissue loss. There is some undermining and tunneling. What stage is this pressure ulcer?

stage III

The nurse is teaching a group of students about physical assessment of the integumentary system. Which statement made by the nursing student indicates the need for further teaching? Select all that apply.

-"I should perform a visual inspection to identify the abnormalities." -"I should perform the assessment in a well-lit area when the client is fully clothed."

The nurse is caring for a client with a pressure injury. Which comorbidities could the nurse expect to treat? Select all that apply.

-Anemia -Peripheral vascular disease -Diabetes

The nurse is assigned to a patient who is preparing to go to surgery for wound debridement. The nurse explains to the patient the purpose of the wound debridement, including which of the following? Select all that apply.

-Facilitates healing -Removal of necrotic tissue -Reduces the risk of infection

The nurse would implement which nursing interventions to decrease the chance of the client developing pressure injury? Select all that apply.

-Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. -Develop and implement a turning schedule if the client is unable to turn independently. -Use a skin risk assessment tool such as the Braden Scale per facility policy.

The nurse is discharging a patient with a wound. What dietary changes should the nurse suggest be increased to improve wound healing? Select all that apply.

-Protein -Zinc -Vitamin C -B Vitamins -Iron

Arrange the steps of obtaining a swab culture chronologically.

-evaluate the wound bed to locate the area. -prepare to use sterile technique to obtain the specimen -clean the entire wound bed using a nonasepic solution -moisten the swab with normal saline -rotate the swab with gentle pressure on the wound tissue -place the swab into sterile container and label it -send the specimen to the laboratory without delay

Because Louanne has a fever, the provider performs lab work and finds that her white blood cell count is elevated. Louanne is admitted to the hospital for intravenous antibiotics. What should the nurse include in the plan of care? Select all that apply.

-wound care to the site -functional assessment -braden scale assessment -positioning so that heal is not resting on the bed -nutritional assessment