Module 21 NCLEX style questions Pressure Ulcers

Hydrocolloid dressing

gel forming polymer such as gelatin, pectin, and carboxymethylcellulose with a strong film or foam adhesive backing. absorb exudate by swelling into a gel like mass and vary from being occlusive to semi permeable. does not attach to actual wound itself and is instead anchored to intact skin surrounding the wound.

Osteomyelitis

inflammation of bone and bone marrow

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?

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.

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?

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.

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.)

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.)

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.

Skin prep granulex

Toughens intact skin and preserves skin integrity Prevents skin breakdown Increases blood supply Adds moisture Contains trypsin to aid in removal of necrotic tissue

low air loss bed

Uses multiple air-filled cushions and varying amounts of air. Can support a wide range of patient weights. Reduces pressure to avoid or alleviate decubitus ulcers.

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.)

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?

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.

Alginate dressing

Soft, absorbent, cotton like, for wounds with exudate, require packing and absorption, absorb a TON

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?

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.

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?

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.

stage 3 pressure ulcer

Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.

Zygomatic bone

cheek bone

Stage 1 pressure ulcer

intact skin with nonblanchable redness

Braden Scale for Predicting Pressure Sore Risk

sensory perception, moisture, activity, mobility, nutrition, friction and shear

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?

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.

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.)

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.

stage 2 pressure ulcer

Skin no longer intact, fleshy pink base with a break in skin integrity This is where Blistering is

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.)

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.

Braden Scale for Predicting Pressure Sore Risk

19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk

A client is in the​ high- Fowler position to facilitate breathing. Which body pressure area should the nurse be most concerned​ about?

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.)

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.

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.)

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.

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?

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.

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

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.)

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.

Deep Tissue Injury (DTI)

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear that is unstageable

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?

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?

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.)

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.

A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being​ prescribed?

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.