Description
Nursing Interventions and Clinical Skills 6th Edition Perry Potter Ostendorf Test Bank
ISBN-13: 978-0323187947
ISBN-10: 0323187943
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Chapter 25: Pressure Ulcers
Perry et al.: Nursing Interventions & Clinical Skills, 6th Edition
MULTIPLE CHOICE
- The nurse is caring for a patient with a small chronic pressure ulcer on the ankle. Which activity can the nurse delegate to nursing assistive personnel (NAP)?
| a. | Measure the wound for length, width, and depth. |
| b. | Reposition the patient at least every 2 hours. |
| c. | Ask the patient to rate the pain during the dressing change. |
| d. | Examine the wound bed for the type and amount of tissue. |
ANS: B
The nurse delegates patient repositioning to the NAP after the dressing change because the NAP is trained to perform this patient care activity. The nurse assesses the wound for type and amount of tissue in the wound bed, measures the wound, and assesses patient pain control because assessment is a major nursing responsibility.
DIF: Cognitive Level: Comprehend REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse admits the patient to the surgical unit and determines that the patient’s Braden scale score is 18. Which does the nurse include in the patient’s initial plan of care?
| a. | Using moisturizing lotion to massage the sacrum |
| b. | Assisting the patient to turn and reposition every 4 hours |
| c. | Keeping the skin clean and dry with frequent bathing |
| d. | Maintaining the head of the bed at approximately 30 degrees |
ANS: D
The nurse elevates the head of the bed to 30 degrees or less to reduce shear forces. If the patient sits in the Fowler’s or semi-Fowler’s position, the lower back and buttocks receive excessive force from the his or her weight pressing into the mattress, which can increase the risk of skin breakdown. Moisturizing lotion applied to areas at risk for friction is indicated for any patient in bed. The nurse avoids massaging the skin over bony prominences such as the sacrum because the tissue lacks supportive structures such as muscle and fat to distribute pressure over a large surface and provide oxygenated blood. Al-though the patient has a slight risk for skin breakdown, repositioning and turning every 4 hours is inadequate to maintain adequate tissue oxygenation. Excessive bathing increases the risk of skin breakdown by stripping the skin of essential oils and moisture. The skin may be kept clean and dry with daily and as-needed bathing using mild soap or commercial bathing products.
DIF: Cognitive Level: Apply REF: Page 666
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- Patients with a dry wound base have a better chance of wound healing if certain approaches are used. Nursing care would be correctly focused on the maximum outcome if which interventions were used?
| a. | Using dry gauze dressings and a liquid antimicrobial into the wound |
| b. | Optimal nutritional support and the use of hydrogel dressings |
| c. | Bathing frequently with soap and the use of transparent film dressings |
| d. | Using nonstick pads and enzymatic débriding agents |
ANS: B
Nutritional support and the use of hydrogel dressings have been found to bring moisture to a dry wound base. Gauze dressings absorb moisture, which is contraindicated, and a liquid antimicrobial is not indicated. Daily bathing with a mild soap is sufficient to keep the area clean. Transparent film dressings are used on partial-thickness wounds with minimal drainage. Nonstick pads are suitable for abrasions so the dressing does not adhere to the wound. Enzymatic débriding agents promote removal of dead tissue.
DIF: Cognitive Level: Apply REF: Page 673
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse assesses a patient with a pressure ulcer. Which assessment datum does the nurse use to support the identification of a stage III pressure ulcer?
| a. | Nonblanching and reddened areas of intact skin |
| b. | Extensive destruction of the skin and muscle |
| c. | Full-thickness skin loss from the surface down to the bone |
| d. | Full-thickness skin loss from the surface down to the fascia |
ANS: D
A stage III ulcer involves damage or necrosis of subcutaneous tissue extending down to, but not through, the fascia. A nonblanching area of reddened skin is a stage I pressure ulcer. Stage IV pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.
DIF: Cognitive Level: Remember REF: Page 667
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse assesses a patient using the Braden scale. A patient having a majority of which number indicates being at great risk for pressure sores?
| a. | 1 |
| b. | 2 |
| c. | 3 |
| d. | 4 |
ANS: A
A score of 1 out of 3 or 4 signifies that the patient is at risk of having a specific problem such as sensory perception, moisture, activity, mobility, nutrition, or friction and shear. A 4 is the highest score possible and indicates no problem in that category. Scores of 2 and 3 aren’t as low and aren’t as critical.
DIF: Cognitive Level: Remember REF: Page 666
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse is caring for four patients at risk for impaired skin integrity. Which patient requires the most frequent assessment and possible intervention?
| a. | A malnourished, homeless patient with a nasogastric tube who is bedridden |
| b. | A college football player with bilateral long leg casts after a motorcycle accident |
| c. | An elderly female ambulating after hip replacement surgery |
| d. | A school-age child recovering from a tonsillectomy and adenoidectomy |
ANS: A
The homeless patient has four major factors that can contribute to skin breakdown: poor nutrition, being homeless, being bedridden, and having a nasogastric tube. The edges of the casts on the football player need to be watched for irritation, but he is at low risk for skin breakdown because of his youth, nutritional status, and activity level. The elderly female after hip replacement surgery would be at risk for skin breakdown at the site of the surgery. Her age would also be a factor because of the decrease of tissue under the skin. The school-age child has no risk factors for skin breakdown.
DIF: Cognitive Level: Apply REF: Page 666
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is assessing a newly admitted patient with a pressure ulcer on the hip. Which clinical indicator does the nurse use to assess a stage II pressure ulcer?
| a. | Deep, open crater |
| b. | Persistent redness |
| c. | Boggy consistency |
| d. | Superficial blistering |
ANS: D
A stage II pressure ulcer is a superficial, partial-thickness skin loss presenting as an abrasion, blister, or shallow crater. A deep crater is consistent with clinical indicators for a stage III or stage IV ulcer. Persistent redness and a boggy or firm consistency are characteristics of a stage I pressure ulcer.
DIF: Cognitive Level: Remember REF: Page 676
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse uses the Braden scale to assess the patient’s pressure ulcer risk. Which patient score mandates that the nurse implement aggressive prevention measures because of being at high risk for skin breakdown?
| a. | Less than 9 |
| b. | 15 to 18 |
| c. | 19 |
| d. | 23 |
ANS: A
A Braden scale score less than 9 indicates that the patient has a very high risk for development of a pressure ulcer. These scores are indicative of a patient who has impaired sensation, very frequent exposure to moisture, moderate-to-severe activity impairment, and inadequate nutrition. Braden scale scores 13 and 14 indicate a moderate risk, scores 15 to 18 indicate a mild risk, and a score above 19 includes patients with the lowest risk for development of pressure ulcers. A patient with a score of 23 has no risk of skin breakdown.
DIF: Cognitive Level: Comprehend REF: Page 666
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The patient is at risk for development of a pressure ulcer. Which problem related to the patient’s iron-deficiency anemia and smoking habit supports the nurse’s decision to address the anemia for prevention of a pressure ulcer?
| a. | Decreased tissue perfusion |
| b. | Decreased mobility impairment |
| c. | Increased skin moisture |
| d. | Increased level of consciousness |
ANS: A
Iron-deficiency anemia and smoking lead to decreased oxygen-carrying capacity of the blood, which increases the risk of cell death. Restoring iron levels improves the oxygen-carrying capacity of the patient’s blood by supplying adequate oxygen for cell metabolism and energy production. Decreased mobility impairment and increased level of consciousness would be desired outcomes and are not problems related to iron-deficiency anemia. Increased skin moisture most often occurs from fecal or urinary incontinence, not anemia.
DIF: Cognitive Level: Apply REF: Page 679
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The patient has a clean partial-thickness wound. Which dressing material should the nurse choose for dressing this ulcer?
| a. | Strip packing |
| b. | Nonstick pads |
| c. | Transparent film |
| d. | Alginate dressings |
ANS: C
Transparent film is a suitable dressing for the clean partial-thickness wound with minimal exudate. Strip packing and alginate dressings are unsuitable for a stage II ulcer because the ulcer does not involve a deep crater suitable for filling with strip packing or alginate for absorption of moderate-to-heavy exudate. Nonstick pads are suitable for abrasions to keep the dressing from adhering to the wound.
DIF: Cognitive Level: Remember REF: Page 679
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse assesses the patient’s pressure ulcer and notes tissue maceration around the wound. Which action does the nurse take to address this issue?
| a. | Eliminates dead space |
| b. | Uses a skin barrier |
| c. | Applies a foam dressing |
| d. | Obtains a wound culture |
ANS: B
Macerated skin around a wound is consistent with tissue exposure to irritating agents or moisture. The nurse cleanses the area gently and applies a moisture barrier to protect the skin. Although skin needs moisture and a moist environment facilitates wound healing, frequent exposure to moisture or other agents that strip the skin of surface protection increases the risk of skin breakdown. Examples of such agents would be urine or feces, especially diarrhea. Macerated skin has no dead space. Moderate-to-heavy exudate is an indication for a foam dressing. A wound culture is not indicated because macerated tissue is not necessarily infected.
DIF: Cognitive Level: Remember REF: Page 677
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient’s pressure ulcer needs packing and has a moderate-to-heavy amount of drainage. Which type of dressing should the wound care nurse use on the ulcer?
| a. | Foam |
| b. | Hydrogel |
| c. | Impregnated gauze |
| d. | Alginate |
ANS: D
An alginate dressing can both absorb various amounts of drainage and be packed into the defect to fill the wound. Foam dressings are suitable for moderate-to-heavy amounts of wound drainage but are not used for packing. A hydrogel dressing is unsuitable for a wound with heavy drainage because it is designed to maintain a moist environment for the wound bed. Impregnated gauze dressings are used for débridement.
DIF: Cognitive Level: Apply REF: Page 677
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- A patient with darkly pigmented skin is on bed rest and is being assessed for a possible stage I pressure ulcer. What datum about the area of concern will best help the nurse determine the correct staging assessment?
| a. | The skin will be slightly broken. |
| b. | The skin color is darker than surrounding tissues. |
| c. | The tissue is the same temperature as surrounding tissues. |
| d. | The skin blanches easily. |
ANS: B
Early detection of pressure ulcers for a patient with dark skin is problematic because initial skin changes are difficult to distinguish. Characteristics of impaired skin integrity for patients with dark skin include changes in skin color, especially skin darkening or areas of purplish or bluish tones as cells begin to exhibit clinical indications of hypoxia. If the skin is already broken, the patient is not “at risk” but rather has a skin integrity issue. The tissue can be warmer or cooler than adjacent tissue. Blanching may not be visible in a person with darkly pigmented skin.
DIF: Cognitive Level: Comprehend REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The patient requires prone positioning for a severe respiratory condition. Which areas are at risk for developing a pressure ulcer and require pillow bridging as a prevention strategy?
| a. | Ears and toes |
| b. | Nose and elbows |
| c. | Occipital area and knees |
| d. | Sacrum and coccyx |
ANS: A
In the prone position, the nurse positions the patient face down on the bed with the head turned to the side or with a special face pillow that has a hollow center. Because of the severe respiratory problem, the nurse most likely positions the patient with the head to the side to provide easy access to the endotracheal tube and the patient’s airway for suctioning. This positioning exposes the dependent ear and the toes of both feet to an increased risk of pressure ulcers from concentrated pressure on a small area; therefore the nurse supports these areas with padding or pillows to distribute the weight over a larger surface evenly. The nose is not at risk with the head turned to the side, and pressure on the elbows is distributed along the length of the ulnar and radial bones. The sacrum and coccyx are not in contact with a hard surface when the patient is prone. The back of the head is in an independent position with the patient in the prone position with the head facing down or to the side, but prone positioning exposes the anterior aspect of the knees to excessive pressure and requires padding to prevent a pressure ulcer.
DIF: Cognitive Level: Analyze REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment, Planning
- A patient has a slight skin breakdown in the perianal area from incontinent stools. For which combination of therapies should the nurse obtain an order?
| a. | Diapers and a moisture barrier ointment |
| b. | Hydrogen peroxide and povidone-iodine |
| c. | Fecal incontinence bag and a protective barrier paste |
| d. | Alginate and transparent film dressings |
ANS: C
Application of a fecal incontinence bag minimizes the amount of fecal matter that will touch the skin. Applying the protective barrier paste to the perineum and surrounding skin after each incontinent episode helps to heal the denuded skin and protect surrounding skin. Diapers keep moisture against the skin, and the moisture barrier ointment is used on intact skin only. Hydrogen peroxide can cause additional tissue damage on broken skin, and povidone-iodine has been found to be ineffective for wound care because it is associated with increased rates of infection. Alginate and transparent film dressings would not be appropriate. Alginate dressings absorb large amounts of exudate in heavily draining wounds, which is not the situation here, and the transparent film dressing would neither protect the skin area nor help it heal.
DIF: Cognitive Level: Apply REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse assesses the patient’s pressure ulcer after 2 weeks of ambulatory wound care and observes pink tissue at the base of the wound. Which should the nurse implement?
| a. | Refer the patient to a dietitian to improve nutrition. |
| b. | Alter the wound care to include a débriding agent. |
| c. | Collaborate with the healthcare provider for wound culture. |
| d. | Recommend a hydrocolloid wound dressing. |
ANS: D
Pink tissue in the wound base is consistent with clinical indicators of granulation tissue; thus the nurse recommends using a hydrocolloid dressing to maintain a moist environment and protect the wound base because a moist environment facilitates healing. The appearance of granulation tissue indicates that the patient’s wound is healing. Unless the patient requests nutritional counseling, it is not indicated. The wound does not contain cellular debris or necrotic tissue; thus débridement is not indicated. The wound does not have clinical indicators of infection, which would include exudate and foul odor.
DIF: Cognitive Level: Apply REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is positioning a patient at risk for development of a pressure ulcer. Which potential pressure point(s) does the nurse relieve by assisting the patient to a side-lying position?
| a. | Symphysis pubis |
| b. | Ischial tuberosities |
| c. | Greater trochanters |
| d. | Occipital prominence |
ANS: D
The nurse positions the patient in the lateral position to prevent pressure on the back of the patient’s head. Pressure can develop over bony prominences when a patient is allowed to remain in one position too long. The patient exerts pressure on the symphysis pubis in the prone position. The nurse assists the patient to the supine position to avoid pressure on the ischial tuberosities and the greater trochanters.
DIF: Cognitive Level: Comprehend REF: Page 676
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse observes a thick, tannish-brown covering over a large wound and needs to stage the wound. What action by the nurse is most appropriate?
| a. | Removing this covering with a sterile forceps and scissors |
| b. | Filling the base of the patient’s ulcer with a silicone lotion |
| c. | Placing a hydrocolloid dressing directly over the tannish-brown covering |
| d. | Deferring staging until the tannish-brown covering has been removed |
ANS: D
The tannish-brown covering is eschar, which has formed as a result of the severe tissue injury. Until the base of the wound can be seen, the true depth and therefore the stage cannot be determined. Eschar is not simply removed; often it is scored, and a solution is put on it to soften it so it can be removed. When the eschar is removed, sterile instruments are used because removing it exposes fresh tissue. If the nurse applies the dressing over eschar, the dressing effectively seals the necrotic tissue onto the wound bed. Silicone lotion is contraindicated for use in a large crater. A hydrocolloid dressing creates its own seal and cannot be used until the eschar has been removed.
DIF: Cognitive Level: Apply REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- One outcome for a patient on bed rest is that the patient has intact skin within 2 weeks. Which rationale pertaining to the patient best justifies the suggestion by the nurse to use a support surface or special mattress?
| a. | It eliminates pain and discomfort. |
| b. | It prevents joint contractures. |
| c. | It eliminates the need for turning. |
| d. | It reduces risks of immobility. |
ANS: D
The nurse recommends a support surface or special mattress for the patient to reduce the risks associated with immobility (i.e., impaired skin integrity) by reducing or relieving pressure on the patient’s skin, especially at the bony prominences. Support surfaces or special mattresses do not eliminate pain and discomfort. Contractures are prevented with range of motion, physical therapy, and splints. The nurse continues to turn and reposition the patient on a support surface as part of care.
DIF: Cognitive Level: Analyze REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The patient’s sacrum has nonblanching redness on Monday. On Wednesday the nurse determines that the pressure ulcer on the patient’s sacrum is stage II despite skin care, including an air-filled mattress overlay. Which is the best nursing intervention to implement?
| a. | Document the extreme progression of the patient’s pressure ulcer. |
| b. | Collaborate with the healthcare provider for physical therapy. |
| c. | Reassess the patient’s need for a different support surface or bed. |
| d. | Increase the frequency of bathing and linen changes as needed. |
ANS: C
The patient’s pressure ulcer is deteriorating. This means that the current skin care plan is unsuccessful and needs reevaluation; thus the nurse should assess the patient for a different support surface. He or she should document the patient’s skin assessment, but the best response to the patient’s deterioration is to reassess the skin care plan and amend it. Nursing collaboration for physical therapy is a reasonable response and potentially benefits the patient on a support surface, especially if the patient is on bed rest; however, the nurse needs to first assess the patient to determine whether physical therapy is indicated for the patient. He or she provides bathing for a patient with a pressure ulcer on a routine and as-needed basis but avoids planning frequent baths and linen changes as therapy because excessive bathing strips the skin of essential moisture and surface oils.
DIF: Cognitive Level: Analyze REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
MULTIPLE RESPONSE
- The nurse is planning care for her patients and is concerned about skin breakdown and delayed wound healing. Which of the following patients are likely to be at a higher risk for wound healing should they develop a pressure ulcer? (Select all that apply.)
| a. | An elderly female patient with mobility issues |
| b. | A young diabetic patient in traction and on bed rest |
| c. | A teenager receiving chemotherapy |
| d. | An elderly man with stage IV congestive heart failure |
| e. | A middle-aged woman with lupus who is having back surgery but is ambulatory |
ANS: A, B, C, D
Risk factors that delay wound healing include age (older adults have a diminished inflammatory response), obesity, diabetes, compromised circulation, malnutrition, immunosuppressive therapy, chemotherapy, and high levels of stress. An elderly female is at risk due to her age even though she is mobile; a diabetic is at risk especially if in traction; the teenager on chemotherapy is at risk due to the chemotherapy, which can also affect nutrition status. The elderly man has two risk factors: his age and circulatory status. The woman with lupus may not be on immunosuppressive therapy and has no age-related risk factors.
DIF: Cognitive Level: Apply REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is concerned about device-related pressure ulcers in her patients. Which of the following interventions should she take?(Select all that apply.)
| a. | Perform frequent skin assessment under devices and tubes. |
| b. | Assess for edema in the skin underlying a tube. |
| c. | Rotate tubes to different positions to relieve pressure. |
| d. | Implement pressure ulcer care bundles. |
| e. | Do not remove the adhesive tape until it is time to remove the device. |
ANS: A, B, C, D
Medical devices known to contribute to pressure ulcers include nasogastric tubes, endotracheal tubes, Foley catheters, and other plastic, rubber, or silicone tubes. It is thought that the device-related pressure ulcer may occur because of poor fixation or positioning of the equipment. To prevent breakdown, the following should be done:
- Frequently perform skin assessment around and under devices and tubes. Frequently assess for edema in the skin underlying a tube or other medical device.
- Remove adhesive tape and assess underlying skin; determine if another type of tape is needed.
- Rotate tubes to different positions to decrease pressure in the area where the tube is in contact with the skin. For example, endotracheal (ET) tubes can be moved from one side of the mouth to the other.
- Double-check and determine that the tube or device is properly positioned and has proper fixation to decrease unnecessary tube movement and skin damage.
- Implement care bundle for pressure ulcer prevention.
DIF: Cognitive Level: Apply REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is delegating care related to her patients to the NAP. Which of the following indicates the nurse is appropriately delegating tasks related to pressure ulcer care? (Select all that apply.)
| a. | The nurse asks the NAP to report any redness in the patient’s skin. |
| b. | The nurse explains to the NAP that the patient will need to be repositioned every 2 hours. |
| c. | The nurse asks the NAP to assess the patient’s risk factors for skin breakdown. |
| d. | The nurse explains to the NAP which positions the patient should be repositioned in. |
| e. | The nurse asks the NAP to record the patient’s nutritional intake. |
ANS: A, B, D, E
The skill of pressure ulcer risk assessment may not be delegated to nursing assistive personnel (NAP). Instruct the NAP about the following:
- Explaining frequency of position changes and specific positions individualized for the patient
- Reviewing need to report to you any redness or break in the patient’s skin or any abrasion from adhesives, tubes, assistive devices, or other medical devices
- Recording the patient’s nutritional intake is important as malnutrition delays wound healing.
DIF: Cognitive Level: Apply REF: Page 675
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
COMPLETION
- Poor _____ ___________ decreases the patient’s ability to feel the sensation of pressure or discomfort.
ANS:
sensory perception
Immobility and inactivity reduce the patient’s ability or desire to independently change position. Poor sensory perception decreases the patient’s ability to feel the sensation of pressure or discomfort.
DIF: Cognitive Level: Remember REF: Page 671
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The rubbing of the tissue against a surface is called ______; it abrades the top layer of skin (epidermis), which makes tissue susceptible to pressure injury.
ANS: friction
DIF: Cognitive Level: Remember REF: Page 674
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- A parallel force that stretches tissue and blood vessels is called _______.
ANS:
shear
Shear is a parallel force that stretches tissue and blood vessels such as when a patient is in a semi-Fowler’s position and slides toward the foot of the bed.
DIF: Cognitive Level: Remember REF: Page 674
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
