Exam 25: Pressure Ulcers

The nurse assesses a patient using the Braden scale.A patient having a majority of which number indicates being at great risk for pressure sores?

The nurse is positioning a patient at risk for development of a pressure ulcer.Which potential pressure point(s)does the nurse relieve by assisting the patient to a side-lying position?

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?

One outcome for a patient on bed rest is that the patient has intact skin within 2 weeks.Which rationale pertaining to the patient best justifies the suggestion by the nurse to use a support surface or special mattress?

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)?

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

The nurse is concerned about device-related pressure ulcers in her patients.Which of the following interventions should she take?(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 patient's sacrum has nonblanching redness on Monday.On Wednesday the nurse determines that the pressure ulcer on the patient's sacrum is stage II despite skin care,including an air-filled mattress overlay.Which is the best nursing intervention to implement?

The nurse is planning care for her 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 wound healing should they develop a pressure ulcer? (Select all that apply.)

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?

2. The rubbing of the tissue against a surface is called ______; it abrades the top layer of skin (epidermis),which makes tissue susceptible to pressure injury.

A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage I pressure ulcer.What datum about the area of concern will best help the nurse determine the correct staging assessment?

The nurse admits the 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 assesses a patient with a pressure ulcer.Which assessment datum does the nurse use to support the identification of a stage III pressure ulcer?

Patients with a dry wound base have a better chance of wound healing if certain approaches are used.Nursing care would be correctly focused on the maximum outcome if which interventions were used?

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 should the nurse implement?

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?

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

3. A parallel force that stretches tissue and blood vessels is called _______.