Olivia McRitchie
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NCLEX Nursing (Medical-Surgical) Quiz on Exemplar 21.3: Pressure Ulcers, created by Olivia McRitchie on 20/03/2018.

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Olivia McRitchie
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Exemplar 21.3: Pressure Ulcers

Question 1 of 24

1

Pressure ulcers can result when pressure on the tissue between a bony prominence and the external surface of the body distorts the capillaries and interferes with normal blood flow.

Select one of the following:

  • True
  • False

Explanation

Question 2 of 24

1

Pressure ulcers can also result from shearing forces that tear and injure blood vessels.

Select one of the following:

  • True
  • False

Explanation

Question 3 of 24

1

Which of the following patients are at risk for getting a pressure ulcer?

Select one or more of the following:

  • A young man who dove into the shallow end of a swimming pool and is now a quadriplegic.

  • An HIV patient who is experiencing a fever of unknown origin.

  • A teenage anorexic patient who was admitted with severe hypoglycemia.

  • A middle aged female with overflow incontinence who is recovering from mastectomy.

  • A teenager admitted in diabetic ketoacidosis who was found to have type 1 diabetes.

Explanation

Question 4 of 24

1

A nurse is caring for an elderly patient who was hospitalized for a myocardial infarction. She judges that he is at risk for pressure ulcers because he is intolerant to activity, elderly, and suffering from a cardiovascular disease. Which of the following interventions are appropriate for the nurse to initiate in order to decrease the patient's risk of developing a pressure ulcer?

Select one or more of the following:

  • Reassessing the patient's risk for pressure ulcers once a week.

  • Gently bathing him with alcohol-free soap in water that is warm.

  • Allowing the patient to use his humidifier

  • Providing him with a smooth, firm, and wrinkle free bed.

  • Utilizing baby powder to reduce friction.

  • Utilizing a lifting device when changing the client's position.

Explanation

Question 5 of 24

1

A nurse is caring for a quadriplegic patient. He is confined to bed due to his immobility. Which of the following interventions are appropriate for preventing pressure ulcers in this patient?

Select one of the following:

  • Elevating the head of the bed to no more than 30 degrees.

  • Rubbing a petroleum-based cream on the patient's bony prominences.

  • Placing the client in a lateral position.

  • Utilizing a draw string sheet that covers the patient's lower to upper back for in-bed movement.

Explanation

Question 6 of 24

1

You are speaking with a group home employee about your immobile patient's risk for pressure ulcers. The employee is not CNA or BSN trained, but has been working with the profoundly handicapped for the past 10 years. Which of the following statements made by the group home employee indicates that she understands what you have just taught her about preventing pressure ulcers?

Select one or more of the following:

  • "I should reposition my client every 2 hours."

  • "I should look for nonblanchable red marks on my client's skin once a week."

  • "I should put my client's doughnut pillow under her heels."

  • "When I sit my client up for meals, it doesn't matter how I place him."

  • "I should place a couple foam pillows under my client's elbows, shoulders, lower back, and hips."

Explanation

Question 7 of 24

1

What stage of pressure ulcer does this describe?

Nonblanchable erythema of intact skin. Usually occurs in a localized area over a bony prominence. The affected area may be painful, and of a different temperature and consistency than the surrounding skin.

Select one of the following:

  • Stage I

  • Stage II

  • Stage III

  • Stage IV

  • Unstagable

Explanation

Question 8 of 24

1

What stage of pressure ulcer does this describe?

Partial thickness skin loss, with dermal involvement. It presents as shallow and open, without sloughing. It may also present as an intact or open blister with pus or blood in it, or as dry and shiny.

Select one of the following:

  • Stage I

  • Stage II

  • Stage III

  • Stage IV

  • Unstagable

Explanation

Question 9 of 24

1

What stage of pressure ulcer does this describe?

Full thickness skin loss, with damage or necrosis of subcutaneous tissue. It's like a deep crater. It can be with or without undermining and tunneling of adjacent tissue. Sloughing may be present, but bone, tendon, and muscle cannot be seen yet. The depth varies depending on anatomical location.

Select one of the following:

  • Stage I

  • Stage II

  • Stage III

  • Stage IV

  • Unstagable

Explanation

Question 10 of 24

1

What stage of pressure ulcer does this describe?

Full thickness skin loss with extensive tissue damage and necrosis. Undermining and tunneling are usually present, along with visability of the muscle, tendon, and bone. Slough or eschar may be present. The ulcer can extend into muscle and supporting structures.

Select one of the following:

  • Stage I

  • Stage II

  • Stage III

  • Stage IV

  • Unstagable

Explanation

Question 11 of 24

1

What stage of pressure ulcer does this describe?

Full thickness tissue loss, with depth completely obscured by slough or eschar in the wound bed.

Select one of the following:

  • Stage I

  • Stage II

  • Stage IV

  • Stage III

  • Unstagable

Explanation

Question 12 of 24

1

A suspected deep tissue injury looks like intact skin with purple discoloration or a blood filled blister. It indicates damage of underlying soft tissue from pressure or shear.

Select one of the following:

  • True
  • False

Explanation

Question 13 of 24

1

Which of the following patients would have a stage II pressure ulcer?

Select one or more of the following:

  • A patient that developed a blood filled blister after being moved in his bed incorrectly.

  • A patient in a nursing home that urinated on himself and was not changed promptly, resulting in skin breakdown.

  • A patient whose home health nurse utilized corn starch to prevent friction and moisture control, resulting in scrapes to the patient's skin.

  • A bedridden patient whose bed was placed in a high-Fowlers position, and during showering was shown to have damage of the subcutaneous tissue.

  • A patient who was not regularly turned during hospitalization, and during changing was shown to have a shallow ulcer on the heel.

Explanation

Question 14 of 24

1

When may surgical debridement of a pressure ulcer be necessary?

Select one or more of the following:

  • When subcutaneous tissue is involved

  • When an eschar is preventing the wound from healing by granulation.

  • When the ulcer is unstagable due to slough or eschar in the wound

  • When slough becomes present.

  • When the ulcer is full thickness rather than partial thickness.

Explanation

Question 15 of 24

1

Which wound dressings are used to treat stage I pressure ulcers?

Select one or more of the following:

  • Skin prep Granulex

  • Hydrocolloid dressing

  • Transparent dressing

  • Wet-to-dry gauze dressing with sterile normal saline

  • Proteolytic enzymes

  • Vacuum assisted closure

Explanation

Question 16 of 24

1

What type of wound dressing would be used for a stage II pressure ulcer?

Select one or more of the following:

  • Skin prep Granulex

  • Hydrocolloid dressing

  • Transparent dressing

  • Wet-to-dry gauze dressing with sterile normal saline

  • Proteolytic enzymes

  • Vacuum-assisted closure

Explanation

Question 17 of 24

1

What type of dressing would be used for stage III pressure ulcers?

Select one or more of the following:

  • Skin prep Granulex

  • Hydrocolloid dressing

  • Transparent dressing

  • Wet-to-dry gauze dressing with sterile normal saline

  • Proteolytic enzymes

  • Vacuum-assisted closure

Explanation

Question 18 of 24

1

What type of dressing would be used for stage IV pressure ulcers?

Select one or more of the following:

  • Skin prep Granulex

  • Hydrocolloid dressing

  • Transparent dressing

  • Wet-to-dry gauze dressing with sterile normal saline

  • Vacuum-assisted closure

Explanation

Question 19 of 24

1

Select from the dropdown lists to complete the text.

Match the drop down option with the type of dressing.

-( Wet-to-dry gauze dressing, Hydrocolloid dressing ): Allows necrotic material to soften and adhere to the gauze, causing debridement of the wound. By doing that, it enhances healing.

-( Skin prep Granulex, Wet-to-dry gauze dressing ): Toughens intact skin, preserves skin integrity, prevents skin breakdown, increased blood supply, adds moisture, aids in removal of necrotic tissue.

-( Vacuum-assisted closure, Transparent dressings ): Creates a negative pressure to help reduce edema, increase blood supply and oxygenation, and decrease bacterial colonization. It also helps promote moist wound healing and granulation tissue formation.

-( Hydrocolloid dressing, Transparent dressings ): Prevents skin breakdown and promotes healing without crust formation over the ulcer. It is permeable to air and water vapor, and it prevents the growth of anaerobic organisms. By doing this, it enhances healing.

-( Proteolytic enzymes, Wet-to-dry gauze dressing ): Serves as debriding agents in inflamed and infected lesions.

-( Transparent dressings, Skin prep Granulex ): Prevents skin breakdown, the entrance of moisture, and the entrance of bacteria. It does, however, allow oxygen and moisture vapor in. By doing this, it enhances healing.

Explanation

Question 20 of 24

1

Transparent and hydrocolloid dressings are still okay if the pressure ulcer is infected.

Select one of the following:

  • True
  • False

Explanation

Question 21 of 24

1

Transparent and hydrocolloid dressings or skin barriers are contraindicated in stage IV pressure ulcers

Select one of the following:

  • True
  • False

Explanation

Question 22 of 24

1

Which of the following does the nurse NOT report when he/she finds a pressure ulcer?

Select one of the following:

  • Procedure performed when the ulcer was found

  • Location of the ulcer related to a bony prominence.

  • Length, width, and depth of the pressure ulcer.

  • Presence of under minding sinus tract, assessed as face on a clock.

  • Color of the wound bed and location of necrosis or eschar.

  • Condition of the wound margins.

  • Integrity of surrounding skin.

  • Signs of infection.

  • Patient complaint of pain or discomfort at wound site.

  • Stage of the ulcer.

Explanation

Question 23 of 24

1

A person who scores a 16 on the Braden Scale is not at risk for a pressure ulcer.

Select one of the following:

  • True
  • False

Explanation

Question 24 of 24

1

A nurse is teaching a client about how to take care of her newly immobilized husband's pressure ulcer. Which of the following statements spoken by the patient's wife indicates that she understands the discharge teaching you have given her about caring for, and preventing another, pressure ulcer?

Select one or more of the following:

  • "I will gently clean the wound on a regular basis."

  • "I will be sure to include yogurt in his breakfast, peanut butter in his lunch, and some sort of lean meat in his dinner."

  • "I will use hot water when I clean his wound."

  • "I will pull our old water mattress out of the garage and have our son help me fill it."

  • "I will be sure that my husband is moved at least once every 2 hours."

  • "I will close the bedroom window when it's cold outside."

  • "I will keep my husband's skin dry."

  • "I will make sure I have a pillow under my husband's heels at all times."

Explanation

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