Pearson Pressure Ulcers

A patient who is prescribed larval therapy for a chronic pressure injury asks why this treatment is being used. Which response should the nurse make to this patient?

"Your ulcer has bacterial growth, and the maggots will decrease the amount of bacteria"

The nurse reviews with a new graduate nurse the care of a patient on an active low-air-loss bed. Which statement by the graduate nurse indicates correct understanding of this patient's care?

"Despite the use of the special mattress, the patient needs to be repositioned every 2 hours."

A patient being treated for a stage 1 pressure injury asks why Granulex is being used. Which statement should the nurse say in response?

"Granulex will increase blood supply to the skin."

The nurse reviews with new nursing staff the importance of supporting human dignity for home care patients who are bedridden. Which statement indicates the review was successful

"We should teach the family how to conduct skin hygiene for the patient."

The nurse reviews with new nursing staff the importance of supporting human dignity for home care patients who are bedridden. Which statement indicates the review was successful?

"We should teach the family how to conduct skin hygiene for the patient."

The nurse caring for an older patient who is becoming increasing immobile teaches the family caregiver how about preventing pressure injuries. Which statement from the family members should indicate to the nurse that teaching was effective?

"We will monitor the diet to ensure adequate daily intake of proteins and calories"

The nurse caring for an older patient who is becoming increasing immobile teaches the family caregiver how about preventing pressure injuries. Which statement from the family members should indicate to the nurse that teaching was effective

"We will monitor the diet to ensure adequate daily intake of proteins and calories."

A patient at risk for a pressure injury responds to verbal commands, has no sensory deficits, has moist skin, ambulates occasionally, makes slight position changes, and eats approximately 50% of each meal. Which Braden scale score should the nurse identify for this patient?

16

The nurse is caring for multiple patients with mobility issues. Which patient should the nurse identify that is most at risk for a pressure injury?

A 96-year-old female who is dependent on staff to move into and out of a wheelchair

The nurse is reviewing medical records for assigned patients. Which patient should the nurse identify as being at the greatest risk for developing a pressure injury?

A patient who is unable to transfer into and out of a wheelchair without assistance

A patient has a pressure injury with deep exudate. Which dressing should the nurse use because it forms a gel when in contact with wound exudate?

Alginate

A patient on bedrest is experiencing frequent episodes of watery diarrhea. Which action should the nurse take to prevent skin breakdown?

Apply a dimethicone-based cream to prevent moisture from collecting on the skin

The nurse identifies that a patient with decreased mental status is at risk for a pressure injury. Which action should the nurse take to maintain skin hygiene and prevent a pressure injury?

Applying lotion to moist skin after bathing

A patient has an area of eschar within a healing wound. Which type of debridement should the nurse expect to be ordered because it does not damage healthy and healing tissue within a pressure injury?

Autolytic

The nurse is reviewing a list of patients who are all at risk for a pressure injury. Which patient should the nurse identify that would benefit the most from a kinetic bed?

Bedridden patient with limited mobility

A patient with a stage 3 pressure injury reports pain at the site which has developed a yellow-white exudate on the wound bed. Which laboratory test should the nurse anticipate being prescribed?

Complete blood count

The nurse is teaching a patient and the family about nutritional interventions to decrease the risk of developing pressure injuries. Which dietary instruction should the nurse include in the teaching?

Ensure adequate intake of carbohydrates, fluids, and vitamin C.

The nurse plans care to reduce a patient's risk for pressure injuries. Which factor should the nurse recall that contributes to the increase in the cell's need for oxygen?

Excessive body heat

The nurse is caring for a patient with a stage 1 pressure injury to the sacrum. Which product should the nurse suggest to help increase the blood supply to the skin of this pressure injury?

Granulex

A patient who is confined to bed is at risk for developing a pressure injury. Which support surface should the nurse request for this patient?

Kinetic bed

Which data is the least important for the nurse to document after re-evaluating an existing pressure injury?

Level of mobility

The nurse is providing teaching to the family caregiver of an older patient who has become increasingly immobile at home. Which instruction should the nurse provide to reduce the patient's risk of developing a pressure injury?

Monitor the diet to ensure adequate intake of proteins and calories

A patient has a pressure injury over the sacrum. Which assessment finding should indicate to the nurse indicates that this injury is in stage 3?

Necrosis of subcutaneous tissue

The nurse is caring for an older adult patient with poor dietary intake and decreased mobility. Which action is least effective in diminishing the risk of pressure injuries?

Offer the patient water before each meal

The nurse preceptor is observing a new graduate nurse who is caring for a patient with limited mobility and fecal incontinence. For which action by the graduate nurse should the preceptor intervene?

Petroleum-based ointment applied to the skin

A patient with pressure injuries has dementia, limited mobility, and lives with an adult daughter. Which should the nurse suggest to the patient's daughter to help reduce the patient's risk for pressure injuries?

Place a memory foam pad on the chair

The nurse is caring for a patient with limited mobility. Which action should the nurse take to prevent a skin injury caused by friction?

Placing the patient in the prone position

The nurse notes that a patient has shearing tissue damage on the skin over their back. Which reason should the nurse consider as the cause of the injury?

Shearing forces as a result of the patient sliding down in the bed and being pulled back up

A patient develops paraplegia after a motor vehicle crash. Which information should the nurse include when teaching the patient to prevent pressure injuries?

Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation

A patient with type 1 diabetes mellitus has a blister on the left heel caused by ill-fitting shoes. Which stage should the nurse document this injury to be?

Stage 2

A patient with a pressure injury on the sacrum has obvious necrosis of subcutaneous tissue. For which pressure stage should the nurse plan care for this patient?

Stage 3

The nurse is reviewing options for preventing pressure injuries with a patient at high risk for skin breakdown. Which support surface should the nurse instruct the patient to avoid?

Supportive backboard

A patient who is bedridden with pressure injuries caused by frequent incontinence feels ignored by their family and is depressed about the situation. Which action should the nurse take to address the patient's situational low self-esteem?

Teach the family how to conduct skin hygiene