Exam 18: Pressure Ulcer Care

In a patient with a stage II pressure ulcer, the nurse describes the wound as:

After teaching a home caregiver how to manage a pressure ulcer, the nurse realizes that further education is needed when the caregiver says:

The nurse is aware that pressure ulcers can occur: (Select all that apply.)

The removal of devitalized tissue in a wound is known as ______________.

The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound.How would the nurse classify this ulcer?

The nurse is caring for four patients during a shift.Which of the following patients is at greatest risk for developing a pressure ulcer?

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site, and the site does feel cooler than the areas immediately around the site.The nurse recognizes that this patient has developed:

A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?

The patient with a nasogastric (NG) tube in place may experience skin breakdown:

A _______________ is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Patients are at risk for developing pressure ulcers on which areas of the body? (Select all that apply.)

When skin layers adhere to the linens and deeper tissue layer move downward, ________ damage occurs.

In a long-term care facility, how often should the nurse reassess a patient for risk of a pressure ulcer?

A patient with anemia is at risk for developing pressure ulcers as a result of which of the following?

The nurse is planning care for her patient who has a stage II pressure ulcer.Care should include which of the following? (Select all that apply.)

When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated.The nurse should:

Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to:

The nurse knows that which of the following factors contribute to the development of pressure ulcers? (Select all that apply.)

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient, to what should the nurse who is performing the assessment pay particular attention?