Nokea
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.
You may also like to solve these questions
Match the following types of wound healing with their examples: Third intention
- A. A traumatic wound first left open to drain and then sutured closed
- B. An appendectomy incision sutured closed
- C. A pressure ulcer being packed with moist gauze
Correct Answer: A
Rationale: Third intention healing involves delayed closure after initial open drainage, as in a traumatic wound later sutured.
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.
During the inflammatory process, which of the following physiological responses occur?
- A. Capillaries dilate, causing erythema and increased warmth at the site of injury.
- B. Leukocytes are shunted away from the site to fight infection.
- C. Leukocytes move into the interstitial space and attack microorganisms.
- D. Red blood cells deliver more oxygen and nutrients to promote healing.
- E. Fluid in the interstitial spaces prevents redness and pain.
- F. Edema causes pressure on nerve endings, resulting in discomfort and pain.
Correct Answer: A,C,D,F
Rationale: During inflammation, capillaries dilate (erythema and warmth), leukocytes migrate to fight infection, red blood cells supply oxygen/nutrients, and edema causes pain. Leukocytes are not shunted away, and fluid does not prevent redness/pain.
While assessing the skin of a patient on bedrest, you notice a pale area over the left hip with a small blister in the center. What action will you take?
- A. Massage the area vigorously with lotion to promote circulation.
- B. Notify the health-care provider that a pressure injury has developed.
- C. Document your findings and assess again in 2 hours.
- D. Order a special gel-filled mattress for the patient.
Correct Answer: B
Rationale: A pale area with a blister suggests a developing pressure injury, requiring immediate notification of the provider for intervention.
A patient comes to the clinic where you are working as a nurse. He had surgery 2 months ago and is very concerned. He asks you to feel the scar on his side. You feel a hard ridge beneath the incision scar extending about 1 cm on either side of the scar. Which response is most appropriate?
- A. This is a normal part of scar healing and strengthening. It will eventually thin out and become less hard.'
- B. This might be a keloid forming, which is an overgrowth of scar tissue. It is not dangerous.'
- C. This is very unusual at this stage of healing. The doctor will need to look at your scar.'
- D. Don't worry. Different people heal at different rates. You must just be a slow healer.'
Correct Answer: A
Rationale: A hard ridge under a scar is normal during the maturation phase of healing and typically softens over time.