Chapter 25: Pressure Ulcers

Chapter 25: Pressure Ulcers

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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: Comprehend          REF:   Page 675

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

2. 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?

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

 

 

ANS:  D

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. Al-though 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: Apply                   REF:   Page 666

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

3. 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?

a.	Using dry gauze dressings and a liquid antimicrobial into 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

 

 

ANS:  B

Nutritional support and the use of hydrogel dressings have been found to bring moisture to a dry wound base. 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: Apply                   REF:   Page 673

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

4. 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?

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

 

 

ANS:  D

A stage III 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 I pressure ulcer. Stage IV pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.

 

DIF:    Cognitive Level: Remember            REF:   Page 667

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

5. 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?

a.	1
b.	2
c.	3
d.	4

 

 

ANS:  A

A score of 1 out of 3 or 4 signifies that the patient is at risk of having a specific problem such as sensory perception, moisture, activity, mobility, nutrition, or friction and shear. A 4 is the highest score possible and indicates no problem in that category. Scores of 2 and 3 aren’t as low and aren’t as critical.

 

DIF:    Cognitive Level: Remember            REF:   Page 666

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment