Exam 26: Pressure Injury Prevention and Care

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?

The nurse assesses the patient's skin.What does the nurse document for this injury?

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?

A patient has a pressure injury with dry wound base.Which action by the nurse provides the most appropriate wound care?

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?

A nurse is caring for four patients who all have a Braden Scale score of 13.What intervention by the nurse is most appropriate?

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?

The nurse is caring for four patients at risk for impaired skin integrity.Which patient requires the most frequent assessment and possible intervention?

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?

The nurse assesses several patients using the Braden Scale.Which patient will need the most intensive interventions?

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?

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 patient has a slight skin breakdown in the perianal area from incontinent stools.For which combination of therapies does the nurse obtain an order?

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.)

The patient has a clean partial-thickness wound.Which dressing material should the nurse choose for dressing this ulcer?

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.)

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?

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?

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?

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?