Skin Integrity/Pressure Ulcers

A female patient who is being treated for self-inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk?

• Albumin level of 3.5 mg/dL

• Total lymphocyte count of 1500/mm3

• Body weight decrease of 5%

• Arm muscle circumference 90% of standard

The nurse is caring for a patient who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

• The nurse places a foam wedge under his body to keep body weight off the patient's back.

• The nurse uses a ring cushion to protect reddened areas from additional pressure.

• The nurse increases the amount of time the head of bed is elevated.

• The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the patient in a chair.

When giving a back rub to an older patient at home, the nurse notices a Stage II pressure ulcer. What nursing interventions would the nurse perform next?

• Please a sterile dressing over the pressure ulcer.

• Use a wet-to-dry dressing on the pressure ulcer.

• Use a nonadherent dressing and changes it every 3 hours

• Use normal saline to clean the pressure ulcer.

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

• Stage I

• Stage II

• Stage III

• Stage IV

The nurse is applying a heating pad to a patient experiencing neck pain. Which nursing action is performed correctly?

• The nurse uses a safety pin to attach the pad to the bedding.

• The nurse covers the heating pad with a heavy blanket.

• The nurse places the heating pad under the patient's neck.

• The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is performing pressure ulcer assessment for patients in a hospital setting. Which patient would the nurse consider to be at greatest risk for developing a pressure ulcer?

• A newborn.

• A patient with cardiovascular disease.

• An older patient with arthritis.

• A critical care patient.

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces?

• A patient sitting in a chair who slides down.

• A patient who lifts himself up on his elbows.

• A patient who lies on wrinkled sheets.

• A patient who must remain on his back for long periods of time.

The nurse is assessing the wounds of patients. Which patients would the nurse place at risk for delayed wound healing? (Select all that apply)

• An older adult who is bedridden.

• A patient with a peripheral vascular disorder.

• A patient who is obese.

• A patient who eats a diet high in Vitamins A and C.

• A patient who is taking corticosteroid drugs.

Which teaching points would the nurse use to explain the development of pressure ulcers to patients and how to prevent them? (Select all that apply)

• Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue.

• Most pressure ulcers occur over the trochanter and calcaneus.

• Generally a pressure ulcer will not appear within the first 2 days in a person who has not moved for an extended peroid of time.

• The skin can tolerate considerable pressure without cell death, but for short periods only.

• The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? (Select all that apply).

• Use whirlpool treatments, if ordered, until the ulcer is considered clean.

• Clean the wound with each dressing change using aggressive motions to remove necrotic tissue.

• Keep the ulcer tissue moist and the surrounding skin dry.

• Pack wound cavities densely with dressing material to promote tissue healing.

• Use a dressing that absorbs exudate but maintains a moist healing environment.