TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 26: Pressure Injury Prevention and Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with a small chronic pressure ulcer on the ankle. Which
activity can the nurse delegate to nursing assistive personnel (NAP)? a. Measure the wound for length, width, and depth. b. Reposition the patient at least every 2 hours. c. Ask the patient to rate the pain during the dressing change. d. Examine the wound bed for the type and amount of tissue. ANS: B
The nurse delegates patient repositioning to the NAP after the dressing change because the NAP is trained to perform this patient care activity. The nurse assesses the wound for type and amount of tissue in the wound bed, measures the wound, and assesses patient pain control because assessment is a major nursing responsibility. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
2. The nurse admits a patient to the surgical unit and determines that the patient’s Braden Scale
score is 18. Which does the nurse include in the patient’s initial plan of care? a. Using moisturizing lotion to massage the sacrum b. Assisting the patient to turn and reposition every 4 hours c. Keeping the skin clean and dry with frequent bathing N d. Maintaining the head of the bed at approximately 30 degrees ANS: D
A Braden score of 18 indicates mild risk for pressure injuries. The nurse elevates the head of the bed to 30 degrees or less to reduce shear forces. If the patient sits in the Fowler’s or semi-Fowler’s position, the lower back and buttocks receive excessive force from the his or her weight pressing into the mattress, which can increase the risk of skin breakdown. Moisturizing lotion applied to areas at risk for friction is indicated for any patient in bed. The nurse avoids massaging the skin over bony prominences such as the sacrum because the tissue lacks supportive structures such as muscle and fat to distribute pressure over a large surface and provide oxygenated blood. Although the patient has a slight risk for skin breakdown, repositioning and turning every 4 hours is inadequate to maintain adequate tissue oxygenation. Excessive bathing increases the risk of skin breakdown by stripping the skin of essential oils and moisture. The skin may be kept clean and dry with daily and as-needed bathing using mild soap or commercial bathing products. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
3. A patient has a pressure injury with dry wound base. Which action by the nurse provides the
most appropriate wound care? a. Using dry gauze dressings and a liquid antimicrobial on the wound b. Optimal nutritional support and the use of hydrogel dressings c. Bathing frequently with soap and the use of transparent film dressings
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