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If a patient had a stage 3 pressure injury, you would expect to see which of the following on assessment?
- A. Erythema of intact skin that does not blanch and is not purple or maroon in color
- B. Intact serum-filled blisters and broken blisters with shallow, pink or red, moist ulcerations
- C. An open area that reveals damage to the epidermis, dermis, subcutaneous tissue, muscle, fascia, tendon, joint capsule, and bone
- D. An open area that extends through the epidermis, dermis, and subcutaneous tissue with possible undermining and tunneling
Correct Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness loss of skin and subcutaneous tissue, often with undermining or tunneling.
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Before you go in the room to change the dressing for your assigned patient, who has a stage 3 pressure injury infected with MRSA, your first priorities will be to
- A. Determine supplies needed for the dressing change.
- B. Obtain appropriate PPE for caring for a patient with MRSA.
- C. Review sterile technique to prevent contaminating the wound.
- D. Review how to assess a stage 3 pressure injury.
- E. Ask the patient how the other nurses have done the dressing change.
Correct Answer: B,C
Rationale: For an MRSA-infected wound, obtaining PPE and reviewing sterile technique are priorities to prevent transmission and further contamination.
A patient has had emergency surgery because of a bowel obstruction. The wound becomes infected with Escherichia coli. This likely occurred because
- A. These bacteria are always present on the skin and easily enter a wound if sterile technique is not used.
- B. These bacteria grow in the absence of oxygen, which is the case in the bowel.
- C. These bacteria are present in the bowel, and with emergency surgery there is no time to perform special bowel preparations.
- D. The patient had poor nutritional intake because these bacteria grow in dying tissue.
Correct Answer: C
Rationale: E. coli, common in the bowel, likely contaminated the wound during emergency surgery due to lack of bowel prep time.
A patient has a black, hard, leathery scab on his left heel. The stage of this injury is
- A. Deep-tissue pressure injury.
- B. Stage 2.
- C. Stage 3.
- D. Unstageable.
Correct Answer: D
Rationale: A black, leathery scab (eschar) indicates an unstageable pressure injury, as the depth cannot be assessed due to necrotic tissue.
Your patient with a stage 3 pressure injury infected with MRSA is on contact precautions. Which of the following PPE will you obtain when you enter his room?
- A. Gloves
- B. Gown
- C. Mask
- D. Goggles
Correct Answer: A,B
Rationale: Contact precautions for MRSA require gloves and a gown to prevent direct contact with the patient or contaminated surfaces.
Which are accurate statements about a deep tissue pressure injury?
- A. It may be caused by a medical device, such as a splint.
- B. It is deep red, maroon or purple colored, and does not blanch.
- C. It may be intact or nonintact skin.
- D. It is at least 2 cm deep or deeper.
- E. It is the result of prolonged pressure and/or shear force.
Correct Answer: A,B,C,E
Rationale: Deep tissue pressure injuries involve non-blanching discoloration, can be intact or nonintact, and result from pressure/shear, often from devices.