pressure injury nclex
A client is in the high- Fowler position to facilitate breathing. Which body pressure area should the nurse be most concerned about?
Rationale: A client in Fowler position has pressure on the heels, pelvis, sacrum, and vertebrae. A client in the lateral position has pressure on the knee and ilium. A client in the prone position has pressure on the zygomatic bone.
The charge nurse receives report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure injuries? (Select all that apply.)
Rationale: A client on bedrest is immobile, which increases the risk for developing pressure injuries. An older adult client is at risk because of the loss of lean body mass, epidermal thinning, decreased skin elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissues. A client with a history of anorexia nervosa is at risk because of inadequate nutrition, which leads to weight loss, muscle atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure injury.
A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to be?
Rationale: A stage 4 pressure injury may be covered with eschar. Eschar is not present in stage 1 or stage 2. Stage 3 pressure injuries may have eschar present, but tissue damage is limited to the subcutaneous tissue.
The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is used? (Select all that apply.)
Rationale: Alginate dressing should be used for stage 2, 3, and 4 without eschar pressure injuries, but not for stage 4 with eschar pressure injuries. An alginate dressing is not used for stage 1 pressure injuries.
The nurse is assisting nursing assistive personnel (NAP) reposition a client who is immobile and has been lying on the left side. For which action by the NAP should the nurse intervene?
Rationale: Clients should not be pulled up in bed, as shearing forces and friction can break down skin tissue. Clients should be lifted instead of being pulled. It is appropriate for the foam wedge to be placed under the client's left side. The skin over bony prominences on the left side should be inspected when the client is turned. It is appropriate to use pillows to keep the client's heels off the bed.
A client who has been sedated and on mechanical ventilation for several days is on a low-air-loss bed; however, the client has a localized purple area of discoloration over the coccyx that does not blanch. Which pressure injury should the nurse suspect for this client?
Rationale: Deep tissue injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly. The assessment does not describe bruising. A stage 1 pressure injury has intact skin with localized redness that does not blanch when pressed. A stage 2 pressure injury has a shallow open wound or blister without sloughing.
The nurse is caring for a client admitted with a pressure injury. Which data should the nurse document when assessing the pressure injury? (Select all that apply.)
Rationale: Documenting the stage of the pressure injury, color of the wound bed, integrity of the surrounding tissue, and signs of infection are of utmost importance. Assessment of home management does not need to be documented.
A client with poor nutritional intake is at high risk for developing pressure injuries. Which device should the nurse identify as appropriate for this client? (Select all that apply.)
Rationale: Gel flotation pads can be used to protect bony prominences and are filled with a substance similar to fat. A static low-air-loss bed is made up of many air-filled cushions that can be reduced under bony prominences and inflated to provide support in other areas. Foam wedges and blocks can be used to prevent bone-on-bone contact and support positioning. Memory foam chair pads distribute weight more evenly over the surface of the seat and can mold to the body. Foam blocks, not rolled blankets, are used to protect heels from shearing and limit pressure.
The nurse is reviewing documentation on a client at risk for developing a pressure injury. Which note in the documentation should indicate to the nurse that the plan of care has been followed correctly?
Rationale: Nutritional consults should be prescribed for clients with inadequate nutritional intake. Clients should be turned every 2 hours. Client comfort and pain should be assessed more often than daily. Nutritional supplements should be given to clients who eat 50% or less of their meals.
A client asks what effect nutrition has on skin integrity. Which response should the nurse make that explains the relationship of nutrition to pressure injury development?
Rationale: Poor dietary intake of kilocalories, protein, and iron has been associated with the development of pressure injuries. An association between minerals and risk of pressure injury development is unknown. Increased intake of protein will not cause pressure injuries to develop.
A client has a follow-up appointment for treatment of a pressure injury. Which client outcome should indicate to the nurse that treatment goals have been met? (Select all that apply.)
Rationale: The client and family demonstrate an understanding of wound care, the wound has decreased in size, and the client has enrolled in a smoking cessation program indicate that nursing interventions and education have been effective. Greenish exudate indicates a possible infection. The client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.
While assessing the skin of a client who has undergone surgery, the nurse observes erythema to the left scapulae. Which action should the nurse take before reassessing the skin to determine if the erythema is a pressure injury?
Rationale: The nurse should reposition the client to remove pressure from the scapulae and then reassess for redness in one-half or three-fourths the time it took to create the reddened area. If the reddened area does not clear, the client has a stage 1 pressure injury. Massaging the scapulae with lotion, applying a warm blanket, or covering the area with a dressing are not the most appropriate actions to take before reassessing the client.
A client with a deep tissue injury and white exudate develops a fever. Which test should the nurse anticipate being prescribed by the healthcare provider?
Rationale: The wound bed can be cultured to determine the organism causing the infection. ESR can determine the presence of osteomyelitis. Serum protein helps establish nutritional status. Urine culture and sensitivity will determine presence of a urinary tract infection (UTI).
The nurse manager observes a new nurse talk with a client with a stroke and decreased mobility about ways to prevent pressure injures. For which statement should the nurse manager intervene?
Rationale: There is no indication the client has decreased mental status. The client should be turned and repositioned every 2 hours. Keeping the skin clean, dry, and moisturized will help prevent tissue damage. A diet with adequate calories, protein, vitamins, and iron will help to prevent skin breakdown. The client can be encouraged to participate by helping to move the left side every 15-30 minutes. Even small adjustments of 10-20 degrees can prevent tissue injury.
The nurse is caring for a client at risk for a pressure injury. Which action should the nurse use to maintain the skin integrity? (Select all that apply.)
Rationale: To maintain skin integrity for clients at risk for pressure injuries, assess the skin upon admission and then daily, using the same screening tool; treat dry skin with moisturizing lotions directly applied to moist skin after bathing; and immediately clean the skin if exposed to urine or feces. Do not scrub the client's skin when bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low humidity.
The nurse is caring for a client with incontinence of urine and sudden onset of watery diarrhea. Which action should be included in the plan of care to maintain skin integrity? (Select all that apply.)
Rationale: To maintain skin integrity of a client with incontinence of urine and stool, the nurse should assess skin systematically at least once a day, clean skin immediately upon soiling and routinely, increase the humidity in the room and limit exposure to cold, and apply a barrier cream to the skin at the greatest risk of breakdown. Bony prominences should not be massaged.
A client is suspected of having a deep tissue injury. Which intervention should the nurse include in the plan of care? (Select all that apply.)
Rationale: To treat a client with a suspected deep tissue injury, the nurse should apply a moisturizing barrier cream, a nonadhesive protective dressing, and consider support surfaces that will remove all pressure from the area. Debridement of wound bed and edges and wet-to-damp dressing changes are not appropriate for deep tissue injuries.
The nurse identifies that a client is at risk for impaired skin integrity. Which intervention should the nurse add to this client's plan of care? (Select all that apply.)
Rationale: Using positioning devices such as pillows or foam wedges to protect bony prominences, not massaging bony prominences, and inspecting the skin daily help prevent skin breakdown. A side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.
The nurse is caring for a client with an open pressure injury with minimal necrotic tissue. Which dressing should the nurse identify as most appropriate for the client?
Rationale: Wet-to-dry gauze dressing with sterile normal saline will soften the necrotic tissue so it will adhere to the gauze and be debrided with the dressing change. Granulex is appropriate for intact skin. Transparent and hydrocolloid dressings help to prevent skin breakdown.
A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being prescribed?
Rationale: When eschar has formed, surgical debridement and removal of necrotic material is necessary. Application of a barrier cream is appropriate for intact skin. Use of petroleum ointment is not appropriate. Application of a moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.
