Pressure Ulcers

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? 1 Replace the wound sponge every 48 hours. 2 Transport the client to the large oxygen pressure chamber. 3 Overlap the edges of intact skin with the sponge. 4 Set the negative vacuum pressure to intermittent.

1. Replace the wound sponge every 48 hours.

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? 1 The client should have been turned regularly. 2 Older clients frequently develop pressure ulcers. 3 The nurse is not responsible to the client's family. 4 Nurses should respect a client's right not to be moved.

1.The client should ha e been turned regularly.

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. 1 "I will elevate the head of the client's bed to 30 degrees." 2 "I will instruct the client to take baths in lukewarm water." 3 "I will advise the client to apply talc directly to the perineum." 4 "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." 5 "I will teach the client to refrain from eating a high-protein and calorie diet."

1."I will elevate the head of the client's bed to 30 degrees." 2."I will instruct the client to take baths in lukewarm water." 4."I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

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? 1 "I will use tepid rather than hot water." 2 "I will clean my skin as soon as soiling occurs." 3 "I will apply powders and talc on the perineum." 4 "I will pat my skin gently rather than rubbing it dry."

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

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? 1 Incontinence and inability to move independently 2 Periodic diaphoresis and occasional sliding down in bed 3 Reaction to just painful stimuli and receiving tube feedings 4 Adequate nutritional intake and spending extensive time in a wheelchair

1. Incontinence and inability to move independently

Which term should the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence caused by pressure? 1 Plantar wart 2 Callus 3 Ingrown nail 4 Hypertrophic ungual labium

2. Callus

What is the etiology for the development of pressure ulcers in an 80-year-old client? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

2. Decreased subcutaneous fat

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. 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence

2.Anorexia 3.Hemiplegia 4.History of diabetes 5.Urinary incontinence

Which disorder of the foot is caused by continual pressure over bony prominences? 1 Corn 2 Plantar wart 3 Hammer toe 4 Hallux rigidus

1. Corn

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. 1.Absorptive dressings 2.Hydrocolloid dressings 3.Transparent film dressings 4.Moist gauze dressings with antibiotics 5.Telfa dressings with antibiotic ointment

2. Hydrocolloid dressings 3. Transparent film dressings 5. Telfa dressings with antibiotic ointment

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1.Maintain the head of the bed at 35 degrees or less. 2.With the help of another staff member, use a drawsheet when lifting the client in bed. 3.Reposition the client at least every 2 hours and support the client with pillows. 4.At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

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

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? 1 "I should gently pat the skin." 2 "I should use mild, heavily fatted soap." 3 "I should wash with tepid rather than hot water." 4 "I should apply powders or talc on a perineum wound."

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

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? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

4. Stage IV

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? 1.Inspecting the skin daily 2.Providing a rubber cushion on which to sit 3.Massaging body lotion over reddened areas 4.Applying a heating pad to bony prominences

1. Inspecting the skin daily

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? 1 Avoiding leg massages 2 Frequent repositioning of client 3 Increasing fiber content in food 4 Encouraging weight-bearing exercises

2. Frequent repositioning of client

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? 1 "I should inspect the client's skin daily." 2 "I should manage the client's incontinence as quickly as possible." 3 "I should properly dispose of the client's contaminated dressings." 4 "I should not worry about what the client eats."

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

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? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

4. Unstageable

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? 1 Vitamin C aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 Vitamin C increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts.

4. Vitamin C is required for collagen production by fibroblasts.

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. 1 Massaging the reddened skin areas 2 Placing pillows between two bony surfaces 3 Using donut-shaped pillows for pressure relief 4 Keeping the head of the bed below 30 degrees 5 Using a bed pillow under the ankles to keep the heels off the bed surface

1. Massaging the reddened skin areas 3. Using donut-shaped pillows for pressure relief

Which key feature does the nurse associate with a stage 2 pressure ulcer? 1 Presence of nonintact skin 2 Development of sinus tracts 3 Damage to the subcutaneous tissues 4 Appearance of a reddened area over a bony prominence

1. Presence of non intact skin

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? 1.Turn and reposition the client every 2 hours. 2.Cover the ulcer with an occlusive transparent dressing. 3.Clean the ulcer with hydrogen peroxide and leave it open to the air. 4.Provide the client with a diet high in vitamin C, zinc, and protein.

1. Turn and reposition the client every 2 hours.

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. 1 "I should use pressure-relieving pads." 2 "I should place a rubber ring under the sacral area." 3 "I should place pillows between two bony surfaces." 4 "I should keep the head of the bed elevated above 30 degrees." 5 "I should keep my heels off the bed surface using a bed pillow under the ankles."

1."I should use pressure-relieving pads." 3."I should place pillows between two bony surfaces." 5."I should keep my heels off the bed surface using a bed pillow under the ankles."

D

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?