Nokea
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.
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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.
An elderly patient who lives alone and has a vascular stasis ulcer on his right leg is most at risk for infection because he
- A. May not see well enough to notice changes in the wound that indicate infection.
- B. Is unable to stay off of his leg, which will compromise circulation to the area.
- C. Does not eat healthy meals, causing a lack of granulation tissue.
- D. Lacks the ability to understand the way that antibiotics work.
Correct Answer: A
Rationale: Poor vision in the elderly can prevent early detection of infection signs, increasing infection risk in chronic wounds like stasis ulcers.
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.
In what order do wounds heal?
- A. Reconstruction phase, maturation phase, inflammatory phase
- B. Inflammatory phase, reconstruction phase, maturation phase
- C. Prodromal phase, symptoms phase, inflammatory phase, reconstruction phase
- D. Symptoms phase, maturation phase, inflammatory phase, reconstruction phase
Correct Answer: B
Rationale: Wounds heal in three phases: inflammatory (immediate response), reconstruction (tissue repair), and maturation (scar formation).
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.