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concept in nursing 2
Pressure ulcers
| Question | Answer |
|---|---|
| The nurse is evaluating a patient’s risk for developing a pressure ulcer. Which patient characteristics does the nurse consider? | -Age -Activity -General health |
| The nurse is caring for a patient with a pressure ulcer determined to be unstageable. What characteristics would the nurse expect? | Eschar is covering wound bed |
| The charge nurse is leading a unit discussion on pressure ulcers. Which statements should the nurse include? | -“The risk is influenced by nutrition and activity.” -“People with an inability to communicate are at high risk.” -“They can be prevented by relieving pressure on the affected areas.” |
| The wound care nurse assesses a group of patients on the unit. Which patient is at risk of developing a pressure ulcer? | A patient with a spinal cord injury. |
| The patient on anticoagulant therapy has a pressure ulcer on the right foot that has a foul odor to the drainage. The patient has good peripheral pulses. The nurse anticipates the health care provider will prescribe which interventions? | -Obtain a wound drainage specimen for culture and sensitivity -Cushion foot to prevent contact between the ulcer and the bed -Have a dietitian evaluate nutrition needs and create a new diet plan |
| The nurse is caring for an immobile older adult who is at high risk for pressure ulcer formation. Which measure is important to prevent pressure ulcer formation in this patient? | Provide foam material for the patient’s heels |
| The nurse assesses a patient with diabetes mellitus who has a pressure ulcer on the heel. Which intervention should the nurse question while the patient is on bedrest? | Application of bilateral knee-high compression socks |
| A nurse is reviewing the electronic medical record of a patient with a stage 2 pressure ulcer to the iliac crest and notices the following entry: “Wound bed is pink with noticeable slough | -- |
| It measures 2 cm * 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing.” Which data is missing from the documentation entry? | Type of drainage |
| The nurse is caring for patient with paraplegia. Which nursing action is important for preventing pressure ulcer formation in this patient? | Ask patient to participate in repositioning whenever possible |
| Which information about pressure ulcer formation should be provided by the nurse to a patient with decreased mobility? | -“Ambulate to the restroom frequently.” -“Place pillows between your legs when sleeping.” -“Shift your weight every 60 minutes while sitting down.” |
Created by:
Lightnning54
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