Nokea
Which one of the following assessment findings makes it impossible to stage a pressure injury?
- A. Purulent drainage
- B. Eschar
- C. Sloughing tissue
- D. Erythema
- E. Drainage
- F. Signs of infection
- G. Undermining
Correct Answer: B
Rationale: Eschar obscures the wound bed, making it impossible to assess the depth and stage of a pressure injury.
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You are caring for a 67-year-old male who had a cerebrovascular accident 3 weeks ago. In addition, he has developed a pressure injury on his right hip. Which of the following data that you collected will be useful in developing a care plan that will address his pressure ulcer?
- A. Last week he weighed 165.5 pounds, and today he weighs 161.8 pounds.
- B. The pressure injury is a stage 3.
- C. He has 250 mL of clear yellow urine in his Foley catheter.
- D. He is not able to sit up in a chair for longer than 15 minutes at a time.
- E. He dislikes cheese, beans, chicken, and fish, but loves steak, eggs, all kinds of nuts, and peanut butter.
- F. His affect is flat.
- G. He has been on an eggcrate mattress while in the hospital.
Correct Answer: A,B,D,E
Rationale: When developing a care plan for a 67-year-old male with a pressure injury, several pieces of collected data are particularly useful. His weight loss from 165.5 to 161.8 pounds over the past week suggests nutritional deficits, which can impair wound healing and should be addressed through dietary interventions. The identification of the pressure injury as stage 3 indicates full-thickness tissue damage and guides the level of wound care required, such as debridement and specialized dressings. His inability to sit in a chair for more than 15 minutes highlights limited mobility, a major risk factor for pressure ulcers, requiring repositioning schedules and pressure-relieving devices. Additionally, while he dislikes some high-protein foods like cheese, beans, chicken, and fish, his preference for steak, eggs, nuts, and peanut butter still offers adequate protein options, which are critical for tissue repair and wound healing. These preferences should be incorporated into his care plan to ensure compliance with nutritional recommendations.
Your patient has a large abdominal wound with copious drainage and many layers of gauze 4x4s in the dressing. The patient develops a skin reaction to the tape due to frequent dressing changes. What might you recommend for this patient?
- A. Change to surgical adhesive instead of tape to hold dressings in place
- B. Call the doctor and ask for an order to decrease dressing change frequency
- C. Ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape
- D. Wrap gauze around the patient's trunk to hold the dressings in place
Correct Answer: C
Rationale: Montgomery straps or an abdominal binder reduce skin irritation by minimizing tape use while securing dressings.
A patient returns from surgery with a left shoulder dressing. A 3-inch diameter spot of red drainage is visible on the anterior portion of the dressing. The health-care provider does not want the dressing disturbed for 24 hours. What will you do?
- A. Call the health-care provider to report the drainage and request a change in orders
- B. Reinforce the dressing by adding several gauze 4x4s over the area
- C. Draw a line on the dressing outlining the drainage, with the date, time, and your initials
- D. Document the drainage in the chart and observe for further drainage over the next several hours
Correct Answer: C,D
Rationale: Outlining and documenting the drainage allows monitoring for expansion without disturbing the dressing, per provider orders.
Which one of the following interventions would you rateas the most important for care of his pressure injury?
- A. Change the wet-to-damp dressing on his right hipwound gid using sterile technique.
- B. Tell dietary service about his food likes and dislikes.
- C. Reposition the patient every 2 hours around the clock,avoiding the right lateral position.
- D. Assess the condition of the pressure injury once daily.
- E. Provide Foley care every shift.
- F. Work to increase the length of time the patient can tolerate sitting in a chair.
Correct Answer: C
Rationale: Frequent repositioning is the most critical intervention in preventing further skin breakdown and promoting healing of pressure injuries. Since the wound is on his right hip, avoiding the right lateral position helps reduce pressure on the affected area, improving circulation and tissue recovery. This intervention directly addresses pressure relief, which is the primary cause of pressure injuries.
A patient's J-P drain should be emptied:
- A. every 2 hours
- B. every 8 hours
- C. when one-half to two-thirds full
- D. only when it needs to be reactivated
- E. when the container is full
Correct Answer: C
Rationale: A J-P drain should be emptied when one-half to two-thirds full to maintain proper suction and prevent complications.