Nokea
The nursing assessment of a pressure injury includes size depth pain odor and color of tissue. What does this evaluate?
- A. Treatment needed
- B. Effectiveness of implementation
- C. Whether improvement is occurring
- D. Need for additional interventions
Correct Answer: C
Rationale: Ongoing assessment of a pressure injury will evaluate whether improvement is occurring.
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To prevent skin breakdown in a wheelchair-bound patient the nurse teaches the patient to shift the patient's weight every ____ minutes.
Correct Answer: 15
Rationale: People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown.
The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails?
- A. Health care provider
- B. RN
- C. CNA
- D. Podiatrist
Correct Answer: D
Rationale: If the patient's nails are extremely hard, a podiatrist should provide care.
The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to:
- A. 20 degrees.
- B. 45 degrees.
- C. 90 degrees.
- D. 30 degrees.
Correct Answer: D
Rationale: Elimination is facilitated with the head of the bed elevated 30 degrees.
Because of its effect on epithelization the LPN/LVN should confirm the order to use ____ or alcohol on a stage 3 pressure injury.
Correct Answer: peroxide
Rationale: Peroxide and alcohol have a negative effect on epithelization of a pressure injury.
The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?
- A. Every 30 minutes
- B. Every 60 minutes
- C. Every 120 minutes
- D. Every 180 minutes
Correct Answer: C
Rationale: The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time.