Pressure ulcer

A medical-surgical nurse is caring for several patients. Which patient would the nurse expect to be at the highest risk for skin breakdown? A. A65-year-old patient who has bowel and bladder incontinence B. A50-year-old patient with deep vein thrombosis to the left leg C. A35-year-old patient who has community-acquired pneumonia D. A 90-year-old patient with Alzheimer's disease and roams the unit

A

The nurse caring for a patient with a stage 2 pressure ulcer expects to prepare the patient for which diagnostic assessment? A. Swab culture B. Wound biopsy C. Electrical stimulation D. Hyperbolic oxygen administration

A

The wound care nurse assesses a group of patients on the unit. Which patient is at risk of developing a pressure ulcer? A. A patient with a spinal cord injury. B. A patient experiencing infectious diarrhea. C. A patient with peripheral vascular disease. D. A patient who ambulates with the assistance of one person.

A

The patient on anticoagulant therapy has a pressure ulcer on the right foot that has a foul odor to the drainage. The patient has good peripheral pulses. The nurse anticipates the health care provider will prescribe which interventions? SAP A. Obtain a wound drainage specimen for culture and sensitivity B. Cushion foot to prevent contact between the ulcer and the bed C. Consult wound care specialist to use a negative-pressure device D. Have a dietitian evaluate nutrition needs and create a new diet plan E. Arrange for the patient to begin hyperbaric oxygen-therapy treatment

A, B, D

The nurse is evaluating a patient's risk for developing a pressure ulcer. Which patient characteristics does the nurse consider? SAP A. Age B. Activity C. Food choices D. Family history E. General health

A, B, E

Which information about pressure ulcer formation should be provided by the nurse to a patient with decreased mobility? Sap A. "Ambulate to the restroom frequently." B. "Have someone bring your meals to your recliner." C. "Place pillows between your legs when sleeping." D. "Shift your weight every 60 minutes while sitting down." E. "Sleep in the same position throughout the night for comfort."

A, C, D

The nurse is caring for a patient with a stage 2 pressure ulcer. Which clinical manifestations does the nurse expect to observe? SAP A. Blistering B. Intact skin C. Exposed muscle D. Skin discoloration E. Skin loss extending to dermis

A, E

A nurse is reviewing the electronic medical record of a patient with a stage 2 pressure ulcer to the iliac crest and notices the following entry: "Wound bed is pink with noticeable slough. It measures 2 cm * 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing." Which data is missing from the documentation entry? A. Measurements B. Type of drainage C. Condition of tissue D. Intervention provided

B

A patient with a pressure ulcer asks the nurse, "How could this have happened?" Which response from the nurse is appropriate? A. "Excess moisture in your skin led to infection." B."Compression of your skin led to a lack of blood flow." C. "Previous skin damage led to scarring and tissue death." D. "Excessive movement of your body resulted in skin damage."

B

The nurse assesses the patient's Braden Scale score and finds the patient is at risk for skin breakdown. Which intervention should the nurse use while the patient is sitting in the chair? A. Pad the patient's heels B. Use a chair seat cushion C. Limit chair time to 4 hours D. Place a pillow under one hip

B

The charge nurse is leading a unit discussion on pressure ulcers. Which statements should the nurse include? A. "They result from a break in the skin." B. "The risk is influenced by nutrition and activity." C. "People with an inability to communicate are at high risk." D. "They can be prevented by relieving pressure on the affected areas." E. They only occur over bony surfaces, where the skin tends to rub against bone."

B, C, D

Upon the initial home visit, the home health nurse notes the patient has a pressure ulcer that is red with a purulent discharge. Which patient information is vital for the home health nurse to obtain from the discharging hospital nurse to properly perform an initial assessment of the patient's pressure ulcer? Select all that apply. A. Immunizations received B. Skin condition at discharge C. Nutritional status prior to discharge D. Successful pressure-relief measures used E. The measurements of the wound prior to discharge

B, D, E

Which conditions put a patient at risk for pressure ulcer development? Select all that apply. A. Cancer B. Depression C. Poor nutrition D. Complete bed rest E. Low body fat

C, D

A patient is admitted with anemia, hypotension, malnutrition, and confusion. Which intervention should be used to prevent the patient from developing pressure ulcers? A. Ensure all meals contain protein-rich foods. B. Administer 2 units of packed red blood cells. C. Infuse medication to increase the blood pressure. D. Reposition the patient in the bed every 1 to 2 hours.

D

The nurse assesses a patient with diabetes mellitus who has a pressure ulcer on the heel. Which intervention should the nurse question while the patient is on bedrest? A. Administering pain medication as needed B. Maintaining head of bed at 30 to 45 degrees C. Leaving the blankets loose at the bottom of the bed D. Application of bilateral knee-high compression socks

D

The nurse is caring for a patient who has had a pressure ulcer for 3 days. When assessing the wound, which finding causes greatest concern for the nurse? A. Amber fluid B. Clear drainage C. Blood-tinged fluid D. Creamy yellow exudate

D

The nurse is caring for a patient with a pressure ulcer determined to be unstageable. What characteristics would the nurse expect? A. Skin is intact B. ulcer is superficial C. Muscle is exposed D. Eschar is covering wound bed

D

The nurse is caring for an immobile older adult who is at high risk for pressure ulcer formation. Which measure is important to prevent pressure ulcer formation in this patient? A. Obtain a swab culture B. Use of The Braden Scale C. Reposition patient every 4 hours D. Provide foam material for the patient's heels

D

The nurse is caring for patient with paraplegia. Which nursing action is important for preventing pressure ulcer formation in this patient? A. Inspect the patient's skin weekly B. Evaluate the patient's pain rating C. Ensure the bed is elevated to 90 degrees D. Ask patient to participate in repositioning whenever possible

D

The first step to pressure ulcer prevention is identification of high-risk patients using The Braden Scale. Use of The Braden Scale and a thorough skin assessment are nursing interventions utilized to predict pressure ulcer risk. The scale determines the level of risk based on the patient's sensory perception, mobility and activity level, nutrition status, skin moisture, and the potential for friction and shear.

Sensory Perception Moisture Activity Mobility Nutrition Friction and shear