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Which of these patients is most at risk for developing a pressure injury?
- A. A well-nourished 54-year-old patient who had a left total knee replacement and is up in the chair twice per day
- B. A 78-year-old with a feeding tube who is nonambulatory and is incontinent of bowels and bladder
- C. A 66-year-old who had a myocardial infarction (heart attack) yesterday and is not eating well because of nausea
- D. A 42-year-old with pneumonia who is receiving IV antibiotics and can only get up to go to the bathroom
Correct Answer: B
Rationale: The 78-year-old patient has multiple risk factors: immobility, incontinence, and likely poor skin integrity, increasing pressure injury risk.
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You are a nurse, and you are running behind schedule on a very busy workday. The UAP offers to change a patient's abdominal dressing for you. She is a first-semester nursing student. Which is the most appropriate response?
- A. That would be great. Don't forget to measure the open area in the middle of her incision for me.'
- B. I know you have been taught to do this in school, so you are not the same as the other UAPs. Go ahead and change the dressing.'
- C. Thanks, but could you help Mr. Wu walk in the hall instead? That way I can get that dressing changed.'
- D. You know you can't do that as a UAP. I would be in big trouble if I let you change that dressing!'
Correct Answer: C
Rationale: UAPs, including nursing students, are not permitted to perform complex tasks like dressing changes, which require nursing judgment. Delegating a simpler task is appropriate.
When you assess a patient's skin, you will pay special attention to the color, noting which of the following?
- A. Excoriation
- B. Erythema
- C. Smoothness
- D. Pallor
- E. Bruising
- F. Jaundice
Correct Answer: B,D,E,F
Rationale: Skin color changes like erythema, pallor, bruising, and jaundice indicate inflammation, poor perfusion, trauma, or liver issues, respectively.
You are caring for a patient with several risk factors for a pressure injury. Which would you avoid when caring for this patient?
- A. Pulling the sheets from beneath the patient so she does not have to turn frequently.
- B. Turning the patient using a lift sheet to prevent her from sliding on the sheets.
- C. Padding the bony prominences to help prevent pressure that could impair circulation.
- D. Turning the patient at least every 2 hours to prevent prolonged pressure in one area.
Correct Answer: A
Rationale: Pulling sheets can cause shear and friction, increasing pressure injury risk. The other options are preventive measures.
A patient is at risk for wound dehiscence as a result of nutritional issues and medical history. Which interventions should be included in the care plan?
- A. Assist the patient to splint the incision with a pillow when coughing.
- B. Enforce strict bedrest with bathroom privileges only.
- C. Administer stool softeners and antinausea medicine promptly.
- D. Obtain VS every 15 minutes.
Correct Answer: A,C
Rationale: Splinting the incision and preventing straining (via stool softeners/antinausea meds) reduce stress on the wound, preventing dehiscence.
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.