18 minute read
Chapter 26: Pressure Injury Prevention and Care
from TEST BANK FOR NURSING INTERVENTIONS & CLINICAL SKILLS, 7TH EDITION BY PERRY, POTTER. Test Bank with
by ACADEMIAMILL
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 OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning 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 d. Maintaining the head of the bed at approximately 30 degrees
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?
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 OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning 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 d. Using nonstick pads and enzymatic débriding agents
3. A patient has a pressure injury with dry wound base. Which action by the nurse provides the most appropriate wound care?
ANS: B
The use of hydrogel dressings have been found to bring moisture to a dry wound base. Nutrition is extremely important for wound healing so the nurse works to optimize the patient’s healthy intake. Gauze dressings absorb moisture, which is contraindicated, and a liquid antimicrobial is not indicated. Daily bathing with a mild soap is sufficient to keep the area clean. Transparent film dressings are used on partial-thickness wounds with minimal drainage. Nonstick pads are suitable for abrasions so the dressing does not adhere to the wound. Enzymatic débriding agents promote removal of dead tissue.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Nonblanching and reddened areas of intact skin b. Extensive destruction of the skin and muscle c. Full-thickness skin loss from the surface down to the bone d. Full-thickness skin loss from the surface down to the fascia
4. The student nurse a patient’s pressure ulcer. Which assessment datum does the student use to support the identification of a stage 3 pressure ulcer?
ANS: D
A stage 3 ulcer involves damage or necrosis of subcutaneous tissue extending down to, but not through, the fascia. A nonblanching area of reddened skin is a stage 1 pressure ulcer. Stage 4 pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. Score of 1 b. Score of 6 c. Score of 14 d. Score of 17
5. The nurse assesses several patients using the Braden Scale. Which patient will need the most intensive interventions?
ANS: B
A score of 6 on the Braden Scale indicates very high risk for pressure injuries. A score of 14 indicates a moderate risk for pressure injuries while 17 indicates mild risk. A patient cannot get a score of 1.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. A malnourished, homeless patient with a nasogastric tube who is bedridden b. A college football player with bilateral long leg casts after a motorcycle accident c. An older adult ambulating after hip replacement surgery d. A school-age child recovering from a tonsillectomy and adenoidectomy
6. The nurse is caring for four patients at risk for impaired skin integrity. Which patient requires the most frequent assessment and possible intervention?
ANS: A
The homeless patient has three major factors that can contribute to skin breakdown: poor nutrition, being bedridden, and having a nasogastric tube. The edges of the casts on the football player need to be watched for irritation, but he is at low risk for skin breakdown because of his youth, nutritional status, and activity level. The older adult after hip replacement surgery would be at higher risk for skin breakdown if he or she were bed- or chair-ridden, although her age is a factor because of the decrease of tissue under the skin. The school-age child has no risk factors for skin breakdown.
DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Deep, open wound b. Persistent redness c. Boggy consistency d. Superficial blistering
7. The nurse is assessing a newly admitted patient with a pressure ulcer on the hip. Which clinical indicator does the nurse use to assess a stage 2 pressure ulcer?
ANS: D
A stage 2 pressure ulcer is a superficial, partial-thickness skin loss presenting as an abrasion, blister, or shallow wound. A deep crater is consistent with clinical indicators for a stage 3 or stage 4 ulcer. Persistent redness and a boggy or firm consistency are characteristics of a stage 1 pressure ulcer.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. Less than 9 b. 15–18 c. 19 d. 23
8. The nurse uses the Braden Scale to assess the patient’s pressure ulcer risk. Which patient score mandates that the nurse implement aggressive prevention measures because of being at high risk for skin breakdown?
ANS: A
A Braden Scale score less than 9 indicates that the patient has a very high risk for development of a pressure ulcer. These scores are indicative of a patient who has impaired sensation, very frequent exposure to moisture, moderate-to-severe activity impairment, and inadequate nutrition. Braden Scale scores 13 and 14 indicate a moderate risk, scores 15–18 indicate a mild risk, and a score above 19 includes patients with the lowest risk for development of pressure ulcers. A patient with a score of 23 has no risk of skin breakdown.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Decreased tissue perfusion b. Decreased mobility impairment c. Increased skin moisture d. Increased level of consciousness
9. The patient is at risk for development of a pressure ulcer. Which problem related to the patient’s iron deficiency anemia and smoking habit supports the nurse’s decision to address the anemia for prevention of a pressure ulcer?
ANS: A
Iron deficiency anemia and smoking lead to decreased oxygen-carrying capacity of the blood, which increases the risk of cell death. Restoring iron levels improves the oxygen-carrying capacity of the patient’s blood by supplying adequate oxygen for cell metabolism and energy production. Decreased mobility impairment and increased level of consciousness would be desired outcomes and are not problems related to iron deficiency anemia. Increased skin moisture most often occurs from fecal or urinary incontinence, not anemia.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Moist gauze b. Foam dressings c. Transparent film d. Alginate dressings
10. The patient has a clean partial-thickness wound. Which dressing material should the nurse choose for dressing this ulcer?
ANS: C
Transparent film is a suitable dressing for this clean partial-thickness wound with minimal exudate. Moist gauze can be used on a dry wound to deliver moisture. Alginate dressings are unsuitable because the ulcer does not need absorption of moderate-to-heavy exudate. Foam dressings prevent dehydration of the wound and absorb exudate.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Measures the wound bed. b. Uses a skin barrier. c. Applies a foam dressing. d. Obtains a wound culture.
11. The nurse assesses the patient’s pressure ulcer and notes tissue maceration around the wound. Which action does the nurse take to address this issue?
ANS: B
Macerated skin around a wound is consistent with tissue exposure to irritating agents or moisture. The nurse cleanses the area gently and applies a moisture barrier to protect the skin. Although skin needs moisture and a moist environment facilitates wound healing, frequent exposure to moisture or other agents that strip the skin of surface protection increases the risk of skin breakdown. Examples of such agents would be urine or feces, especially diarrhea. Measuring the wound bed is an appropriate nursing assessment, but does not address the macerated tissue. Moderate-to-heavy exudate is an indication for a foam dressing. A wound culture is not indicated because macerated tissue is not necessarily infected.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Foam b. Hydrogel c. Impregnated gauze d. Calcium alginate
12. The patient’s pressure ulcer needs packing and has a moderate -to-heavy amount of drainage. Which type of dressing should the wound care nurse use on the ulcer?
ANS: D
An alginate dressing can both absorb various amounts of drainage and be packed into the defect to fill the wound. Foam dressings are suitable for moderate-to-heavy amounts of wound drainage but are not used for packing. A hydrogel dressing is unsuitable for a wound with heavy drainage because it is designed to maintain a moist environment for the wound bed. Impregnated gauze dressings are used for débridement.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. The skin will be slightly broken. b. The skin color is darker than surrounding tissues. c. The tissue is the same temperature as surrounding tissues. d. The skin blanches easily.
13. A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage 1 pressure injury. What datum about the area of concern will best help the nurse determine the correct staging assessment?
ANS: B
Early detection of pressure ulcers for a patient with dark skin is problematic because initial skin changes are difficult to distinguish. Characteristics of impaired skin integrity for patients with dark skin include changes in skin color, especially skin darkening or areas of purplish or bluish tones as cells begin to exhibit clinical indications of hypoxia. If the skin is already broken, the patient is not “at risk” but rather has a skin integrity issue. The tissue can be warmer or cooler than adjacent tissue. Blanching may not be visible in a person with darkly pigmented skin.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. Chin and knees b. Nose and elbows c. Occipital and parietal areas d. Sacrum and coccyx
14. The patient requires prone positioning for a severe respiratory condition. Which areas are at risk for developing a pressure ulcer and require pillow bridging as a prevention strategy?
ANS: A
In the prone position, the nurse positions the patient face down on the bed with the head turned to the side or with a special face pillow that has a hollow center. Areas subject to pressure injury in this position include the chin, knees, and pre-tibial crest. The other areas are not subject to excessive pressure in the prone position.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment | Nursing Process: Planning a. Moisture barrier ointment b. Hydrogen peroxide for cleansing c. Fecal incontinence bag d. Calcium alginate dressings
15. A patient has a slight skin breakdown in the perianal area from incontinent stools. For which combination of therapies does the nurse obtain an order?
ANS: C
A moisture barrier ointment will protect the perianal skin from further breakdown from exposure to fecal material.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Refer the patient to a dietitian to improve nutrition. b. Alter the wound care to include a débriding agent. c. Collaborate with the health care provider for wound culture. d. Recommend a hydrocolloid wound dressing.
16. The nurse assesses the patient’s pressure ulcer after 2 weeks of ambulatory wound care and observes pink tissue at the base of the wound. Which intervention by the nurse is most appropriate?
ANS: D
Pink tissue in the wound base is consistent with clinical indicators of granulation tissue; thus the nurse recommends using a hydrocolloid dressing to maintain a moist environment and protect the wound base because a moist environment facilitates healing. The appearance of granulation tissue indicates that the patient’s wound is healing. The patient may or may not need a referral to a dietitian and the nurse would assess for nutritional deficits that would make this referral appropriate. The wound does not contain cellular debris or necrotic tissue; thus débridement is not indicated. The wound does not have clinical indicators of infection, which would include exudate and foul odor.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Symphysis pubis b. Ischial tuberosities c. Greater trochanters d. Occipital prominence
17. The nurse is positioning a patient at risk for development of a pressure injury. Which potential pressure point(s) does the nurse relieve by assisting the patient to a side-lying position?
ANS: D
The nurse positions the patient in the lateral position to prevent pressure on the back of the patient’s head. Pressure can develop over bony prominences when a patient is allowed to remain in one position too long. The patient exerts pressure on the symphysis pubis in the prone position although it is not common. The nurse assists the patient to the supine position to avoid pressure on the ischial tuberosities and the greater trochanters.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Removing this covering with a sterile forceps and scissors b. Filling the base of the patient’s ulcer with a silicone lotion c. Placing a hydrocolloid dressing directly over the tannish-brown covering d. Deferring staging until the brown covering has been removed
18. The nurse observes a thick, dark brown covering over a large wound and needs to stage the wound. What action by the nurse is most appropriate?
ANS: D
The dark brown covering is eschar, which has formed as a result of the severe tissue injury. Until the base of the wound can be seen, the true depth and therefore the stage cannot be determined. Eschar is not always removed. If the nurse applies the dressing over eschar, the dressing effectively seals the necrotic tissue onto the wound bed. Silicone lotion is contraindicated for use in a large crater. A hydrocolloid dressing creates its own seal and cannot be used until the eschar has been removed.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. It eliminates pain and discomfort. b. It prevents joint contractures. c. It eliminates the need for turning. d. It reduces risks of immobility.
19. Which rationale pertaining to a patient best justifies the suggestion by the nurse to use a support surface or special mattress?
ANS: D
The nurse recommends a support surface or special mattress for the patient to reduce the risks associated with immobility (i.e., impaired skin integrity) by reducing or relieving pressure on the patient’s skin, especially at the bony prominences. Support surfaces or special mattresses do not eliminate pain and discomfort. Contractures are prevented with range of motion, physical therapy, and splints. The nurse continues to turn and reposition the patient on a support surface as part of care.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Document the extreme progression of the patient’s pressure ulcer. b. Collaborate with the health care provider for physical therapy. c. Reassess the patient’s need for a different support surface or bed. d. Increase the frequency of bathing and linen changes as needed.
20. The patient’s sacrum has nonblanching redness on Monday. On Wednesday the nurse determines that the pressure ulcer on the patient’s sacrum is stage 2 despite skin care, including an air-filled mattress overlay. Which is the best nursing intervention to implement now?
ANS: C
The patient’s pressure ulcer is deteriorating. This means that the current skin care plan is unsuccessful and needs reevaluation; thus, the nurse should assess the patient for a different support surface. He or she should document the patient’s skin assessment, but the best response to the patient’s deterioration is to reassess the skin care plan and amend it. Nursing collaboration for physical therapy is a reasonable response and potentially benefits the patient on a support surface, especially if the patient is on bed rest; however, the nurse needs to first assess the patient to determine whether physical therapy is indicated for the patient. He or she provides bathing for a patient with a pressure ulcer on a routine and as-needed basis but avoids planning frequent baths and linen changes as therapy because excessive bathing strips the skin of essential moisture and surface oils.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Reduces the need to turn the patient frequently. b. Provides real-time data regarding pressure on patient surfaces. c. The alarm alerts the staff when the patient tries to exit the bed. d. They adjust the flow of air in specialty beds.
21. The student nurse is caring for a patient with a continuous bedside pressure mapping device and asks the faculty to explain the purpose of this intervention. What response by the faculty is best?
ANS: B
A continuous bedside pressure mapping device provides real-time data about pressure the patient’s body surfaces are encountering. The staff would use this data to reposition the patient as needed, guided by the pressure images. It does not reduce the need to turn patients often, alarm when the patient attempts to get up, or adjust the flow of air in specialty beds.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Delegate turning all the patients at the same time. b. Consult the wound-ostomy-continence nurse. c. Assess the factors that increase each patient’s risk. d. Request specialty beds or overlays for each patient.
22. A nurse is caring for four patients who all have a Braden Scale score of 13. What intervention by the nurse is most appropriate?
ANS: C
Many factors are assessed with the Braden Scale, including sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The nurse would plan care based on the individual factors that increase each patient’s risk of pressure injury. This holistic approach would have the best chance of being successful. Turning all patients at the same time is not individualizing care. The nurse may or may not need to consult the wound-ostomy-continence nurse. Depending on the risk factors, a specialty bed or overlay may be appropriate for some patients.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Stage 1 pressure injury b. Stage 2 pressure injury c. Incontinence dermatitis d. Unstageable injury
23. The nurse assesses the patient’s skin. What does the nurse document for this injury?
ANS: B
N
This picture shows a stage 2 pressure injury.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
Multiple Response
1. The nurse is planning care for a group of patients and is concerned about skin breakdown and delayed wound healing. Which of the following patients are likely to be at a higher risk for impaired wound healing should they develop a pressure ulcer? (Select all that apply.)
a. An elderly patient with mobility issues b. A young diabetic patient in traction and on bed rest c. A teenager receiving chemotherapy d. An elderly person with stage IV congestive heart failure e. A middle-aged patient with frequent headaches having back surgery
ANS: A, B, C, D
Risk factors that delay wound healing include age (older adults have a diminished inflammatory response), obesity, diabetes, compromised circulation, malnutrition, immunosuppressive therapy, chemotherapy, and high levels of stress. An elderly person is at risk due to age; a diabetic is at risk especially if in traction; the teenager on chemotherapy is at risk due to the chemotherapy, which can also affect nutrition status and immunity. The elderly patient with heart failure has two risk factors: his age and circulatory status. The patient with frequent headaches having back surgery currently has no specific risk factors.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Perform frequent skin assessment under devices and tubes. b. Remove the device periodically to protect the skin. c. Rotate tubes to different positions to relieve pressure. d. Implement pressure injury care bundles. e. Do not remove the adhesive tape until it is time to remove the device.
2. The nurse is concerned about device-related pressure ulcers in a group of patients. Which of the following interventions are most appropriate to reduce this risk? (Select all that apply.)
ANS: A, C, D
Medical devices known to contribute to pressure ulcers include nasogastric tubes, endotracheal tubes, urinary catheters, and other plastic, rubber, or silicone tubes. It is thought that the device-related pressure ulcer may occur because of poor fixation or positioning of the equipment. To prevent breakdown, the following should be done:
1. Frequently perform skin assessment around and under devices and tubes.
2. Remove adhesive tape and assess underlying skin; determine if another type of tape is needed.
3. Rotate tubes to different positions to decrease pressure in the area where the tube is in contact with the skin. For example, endotracheal (ET) tubes can be moved from one side of the mouth to the other.
4. Double-check and determine that the tube or device is properly positioned and has proper fixation to decrease unnecessary tube movement and skin damage.
5. Implement care bundle for pressure ulcer prevention.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. The nurse asks the NAP to report any redness in the patient’s skin. b. The nurse explains to the NAP to reposition the patient every 2 hours. c. The nurse asks the NAP to assess the patient’s risk factors for skin breakdown. d. The nurse explains to the NAP which positions the patient should be repositioned in. e. The nurse asks the NAP to record the patient’s nutritional intake.
3. The nurse is delegating care to the NAP. Which of the following indicates the nurse is appropriately delegating tasks related to pressure ulcer care? (Select all that apply.)
ANS: A, B, D, E
The skill of pressure ulcer risk assessment may not be delegated to nursing assistive personnel (NAP). Instruct the NAP about the following:
1. Explaining frequency of position changes and specific positions individualized for the patient.
2. Reviewing need to report to you any redness or break in the patient’s skin or any abrasion from adhesives, tubes, assistive devices, or other medical devices.
3. Recording the patient’s nutritional intake is important as malnutrition delays wound healing.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Calcium b. Protein c. Vitamin C d. Zinc e. Selenium
4. A malnourished patient has a deep pressure injury. The nurse collaborates with the patient to obtain foods containing which substances in meals and snacks to benefit wound healing? (Select all that apply.)
ANS: B, C, D
Malnutrition delays wound healing. Nutrients important to healing include protein, vitamin C, and zinc. Calcium and selenium are substances found in a healthy diet, but do not specifically contribute to wound healing.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Oxygen mask b. Indwelling catheter c. Compression stockings d. Immobilization devices e. Nasogastric tubes
5. Which medical devices place the patient at risk for device-related pressure injury? (Select all that apply.)
ANS: A, B, C, D, E
Any medical device touching the patient can lead to pressure injury.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
MATCHING a. Decreased inflammatory response b. Causes vasoconstriction c. Presence of less vascular tissue d. Immunosuppression and decreased collagen synthesis e. Vascular changes and leukocyte malfunction 1.
Match the patient factors to the pathophysiology of delayed wound healing.
4. Diabetes
5. Corticosteroids
1. ANS: C DIF: Cognitive Level: Remembering
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: Fatty tissue has reduced blood supply because it is less vascular.
2. ANS: B DIF: Cognitive Level: Remembering
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: Smoking leads to vasoconstriction.
3. ANS: A DIF: Cognitive Level: Remembering
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: A normal age-related change is a decrease in the immune system functioning, including reduction in the inflammatory response which is needed for healing.
4. ANS: E DIF: Cognitive Level: Remembering
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: Exposure to high blood glucose in diabetes has many deleterious effects, including vascular changes that reduce blood flow to tissues and leukocyte malfunction.
5. ANS: D DIF: Cognitive Level: Remembering
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MSC: Use of corticosteroids can cause immunosuppression and decreased collagen synthesis.
