Week 9 HESI

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action?

Turn and reposition the client every 2 hours. Turning and repositioning immobile clients at least every 2 hours is the best initial nursing action for preventing further skin breakdown. Other measures should also be taken to relieve pressure on the area to prevent progression and promote healing.

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.

"I should use pressure-relieving pads." "I should place pillows between two bony surfaces." "I should keep my heels off the bed surface using a bed pillow under the ankles." The client should use pressure-relieving pads to prevent pressure ulcers. Place a pillow between two bony surfaces to prevent pressure. Keeping the heels off the bed surface using a bed pillow under ankles gives uniform positioning and reduces pressure.

Which term should the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence caused by pressure?

Callus

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of non-intact skin

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

With the help of another staff member, use a drawsheet when lifting the client in bed. Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force.

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?

Incontinence & inability to move

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.

Massaging the reddened skin areas Using donut-shaped pillows for pressure relief The client with a pressure ulcer should gently pat the skin rather than massaging the reddened skin areas, which results in dryness. Using donut shaped pillows may aggravate the client's condition.

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?

The client should have been turned regularly. Clients should change position at least every 2 hours to prevent pressure ulcers. The nurse should not deviate from this standard of practice because of the cognitively impaired client's refusal to move.

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?

"I should apply powders or talc on a perineum wound." A client should not use powders or talc on the perineum wound, and the nurse needs to follow up to correct this misconception.

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.

"I will elevate the head of the client's bed to 30 degrees." "I will instruct the client to take baths in lukewarm water." "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." The client's bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk of pressure ulcers. The client should take baths with lukewarm water and not hot water. It is very important to maintain the client's fluid intake of 2000 to 3000 mL/day, which helps to nourish the skin.

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.

Anorexia Hemiplegia History of diabetes Urinary incontinence Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this affects the categories of mobility, activity, and friction on the Braden Scale. Clients with a history of diabetes can also have peripheral neuropathy, causing numbness or loss of sensation in the hands in feet; sensory perception is a category on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale.

The nurse is assessing four clients with foot disorders. Which client is instructed to use bunion pads to relieve pressure on the bursal sac?

Client A

Which disorder of the foot is caused by continual pressure over bony prominences?

Corn

What is the etiology for the development of pressure ulcers in an 80-year-old client?

Decreased subcutaneous fat. In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers.

Which practice would be suitable in the prevention of a pressure ulcer?

For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces.

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?

Frequent repositioning of client. In clients in a bed or wheelchair this will relieve pressure points, thereby decreasing pressure ulcers.

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?

Inspecting the skin daily. Because the client is paralyzed and movement is compromised, daily inspection to determine the presence of reddened areas [1] [2] or lesions is necessary so that treatment can be initiated quickly.

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?

The sponge generally is changed every 48 to 72 hours. Routine changing of the sponge minimizes growth of granulation tissue into the foam sponge and allows for assessment of the wound.

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?

Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged.

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?

Vitamin C is required for collagen production by fibroblasts. Vitamin C aids in capillary synthesis and collagen production by fibroblasts.

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.

Hydrocolloid dressings Transparent film dressings Telfa dressings with antibiotic ointment Hydrocolloid dressings, transparent film dressings, and telfa dressings with antibiotic ointment are beneficial for the healing of a red wound caused by pressure ulcers. Absorptive dressings and moist gauze dressings with antibiotics are used to treat yellow wounds, such as wounds with nonviable necrotic tissue.

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?

Stage IV A stage IV pressure ulcer involves full-thickness tissue loss and the tendons, bones, or muscles are exposed