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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.
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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.
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. Which of the following actions is a priority as a result of this assessment data?
- A. Obtain wound cultures.
- B. Start antibiotic therapy.
- C. Redress the wound with wet-to-dry dressings.
- D. Continue to monitor the wound for purulent drainage.
Correct Answer: A
Rationale: The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.
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 nurse is caring for a patient with a systemic bacterial infection who has 'goose pimples,' feels cold, and rigors. At this stage of the febrile response, which of the following assessments should the nurse monitor?
- A. Skin flushing
- B. Muscle cramps
- C. Rising body temperature
- D. Decreasing blood pressure
Correct Answer: C
Rationale: The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.
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.