Pressure Ulcers

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? 6 12 16 21

16 The patient's Braden score would be: sensory perception: no impairment (4); moisture: moist (2); activity: walks occasionally (3); mobility: slightly limited (3); nutrition: probably inadequate (2); friction and shear: potential problem (2). The total score would be 16.

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 admitted to the step down unit recovering from pneumonia A patient who is unable to transfer into and out of a wheelchair without assistance A patient admitted to the obstetrical unit at 33 weeks' gestation and on bedrest A patient who experienced a stroke 6 months ago and has residual left-sided weakness

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? Hydrofiber Alginate Proteolytic enzymes Hydrocolloid

Alginate Alginate dressings form a gel when in contact with wound exudate from pressure injuries. Proteolytic enzymes, hydrocolloid dressings, and hydrofiber dressings do not form a gel with wound exudate.

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 Arteral blood gas (ABG) Serum protein Hemoglobin and hematocrit

Complete blood count

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? Diminished sensation Inadequate nutrition Immobility Excessive body heat

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? Hydrogel dressing Transparent dressing Granulex Vacuum-assisted closure

Granulex

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? Nonblanchable erythema of intact skin Skin loss to the dermis Necrosis of subcutaneous tissue Damage identified to muscle and bone

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 nutritional supplements high in protein and iron. Assess the patient's ability to swallow. Offer the patient water before each meal. Sit with the patient during mealtimes to encourage eating.

Offer the patient water before each meal.

The nurse is caring for a patient with limited mobility. Which action should the nurse take to prevent a skin injury caused by friction? Avoiding use of a draw sheet when repositioning the patient Sprinkling baby powder on the sheets to keep the skin dry Elevating the head of the bed to a 60-degree angle Placing the patient in the prone position

Placing the patient in the prone position

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 3 Stage 2 Stage 4 Stage 1

Stage 2

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 Teach the patient how to perform skin hygiene Encourage the family to spend more time with the patient Encourage the family to bring the patient to the healthcare provider more often

Teach the family how to conduct skin hygiene

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 creates a negative pressure to reduce edema." "Granulex softens intact skin." "Granulex removes moisture to aid in removal of necrotic tissue." "Granulex will increase blood supply to the skin."

"Granulex will increase blood supply 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? "Keep in bed instead of sitting in a chair." "Place a memory foam pad on the chair." "Reposition in the chair every 3 hours." "Use a more comfortable chair."

"Place a memory foam pad on the chair."

A patient with an infected chronic pressure injury is prescribed larval therapy. Which information should the nurse include when teaching the patient about this treatment approach? "The maggots secrete an enzyme that will make your ulcer less painful." "The maggots will secrete compounds that will reduce bacterial growth on your ulcer." "The maggots are the fastest method for treating an ulcer." "The maggots will help your ulcer to drain."

"The maggots will secrete compounds that will reduce bacterial growth on your ulcer."

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 encourage the patient's family to bring the patient to the healthcare provider more often." "We should teach the patient to be self-reliant in the care for skin hygiene." "We should encourage the family to speak to the patient more often." "We should teach the family how to conduct skin hygiene for the patient."

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

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 Monitoring the skin once a week during bathing Using hot water and mild soap during bathing Massaging bony prominences during bathing

Applying lotion to moist skin after bathing

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? A patient admitted to the obstetrical unit on bedrest A patient with paraplegia confined to a wheelchair A patient with left-sided weakness following a stroke Bedridden patient with limited mobility

Bedridden patient with limited mobility

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. Decrease the intake of carbohydrates and fats. Decrease the intake of protein. Eat larger meals three times per day and avoid snacking.

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

Which data is the least important for the nurse to document after re-evaluating an existing pressure injury? Color of the wound bed Level of mobility Location in relation to bony prominences Signs of infection

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? Massage the bony prominences daily. Use an alcohol-based sanitizer to clean the skin after incidences of incontinence. Monitor the diet to ensure adequate intake of proteins and calories. Help the patient to move at least every 4 hours.

Monitor the diet to ensure adequate intake of proteins and calories.

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? Skin washed with soap and warm water Dimethicone-based cream applied to the skin Petroleum-based ointment applied to the skin Skin cleaned well and dried completely before reapplying an adult diaper

Petroleum-based ointment applied to the skin

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 that interrupt blood flow in capillary beds, resulting in tissue ischemia Shearing forces as a result of the patient sliding down in the bed and being pulled back up External pressure on bony prominences for more than 2 hours External pressure that tears and damages blood vessels

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? Baby powder can be applied to bony prominences to prevent skin breakdown Reposition every 4 hours if using a special mattress Use the trapeze to help slide up to the head of the bed Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation

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

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 1 Stage 4 Stage 3 Stage 2

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? Kinetic bed High-air-loss bed Supportive backboard Foam overlay mattress

Supportive backboard