Nokea
A patient is admitted to the hospital with a pressure injury on the left buttock. The nurse notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the following pressure injury wound stages should the nurse document?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: A stage 3 pressure injury has full-thickness skin damage and extends into the subcutaneous tissue. A stage 1 pressure injury has intact skin with some observable damage such as redness or a boggy feel. Stage 2 pressure injuries have partial-thickness skin loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.
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The nurse is caring for an adult patient with stage 3 pressure injuries on both heels who has been in hospital for 6 days. Which of the following timeframes for wound assessment is accurate when a patient is in the acute care setting?
- A. Every 4 hours
- B. Every 6 hours
- C. Every 12 hours
- D. Every 24 hours
Correct Answer: D
Rationale: In acute care, the patient should be reassessed every 24 hours. In long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and at least monthly or every 3 months thereafter.
A patient who is confined to bed and who has a stage 2 pressure injury is being cared for in the home by family members. To prevent further tissue damage, which of the following actions should the nurse instruct the family members that it is most important?
- A. Change the patient's bedding frequently.
- B. Use a hydrocolloid dressing over the injury.
- C. Record the size and appearance of the pressure injury weekly.
- D. Change the patient's position every 2 hours.
Correct Answer: D
Rationale: The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions also may be included in family teaching, but the most important instruction is to change the patient's position every 2-4 hours.
Which of the following nursing actions is most likely to detect early signs of infection in a patient who is taking immuno-suppressive medications?
- A. Monitor white blood cell count
- B. Check the skin for areas of redness.
- C. Check the temperature every 2 hours.
- D. Ask about fatigue or feelings of malaise.
Correct Answer: D
Rationale: Common clinical manifestations of inflammation and infection are frequently not present when patients receive immuno-suppressive medications. The earliest manifestation of an infection may be 'just not feeling well'.
The charge nurse observes a new graduate performing a dressing change on a patient with a stage 2 left heel pressure injury. Which of the following actions by the new graduate indicates a need for further education about pressure injury care?
- A. Uses a hydrocolloid dressing (DuoDerm) to cover the injury.
- B. Inserts a sterile cotton-tipped applicator into the pressure injury.
- C. Irrigates the pressure injury with a 30-ml syringe using sterile saline.
- D. Cleans the injury with a sterile dressing soaked in half-strength hydrogen peroxide.
Correct Answer: D
Rationale: Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.
The nurse is planning care for a patient and is preparing to complete a wet-to-dry dressing. Which of the following wound descriptions is appropriate for using this type of dressing?
- A. Pressure injury with pink granulation tissue
- B. Surgical incision with pink, approximated edges
- C. Full-thickness burn filled with dry, black material
- D. Wound with purulent drainage and dry brown areas
Correct Answer: D
Rationale: Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.