WCLN PI knowledge test

A low modified Braden Score is associated with increased pressure injury risk.

• True

• False

Ms. CHAN, 80 years old and just admitted, has a history of old CVA and hypertension. You've found that Ms. CHAN:

(a) Walks with one assistant;

(b) A lesion over sacrum is found during skin assessment and is believed to be related to a past history of PI, as confirmed with his caregiver

(c) Eats over half of most meals and has normal diet

What is the risk of his Modified Braden Score?

• High Risk

• Moderate Risk

• Low Risk

In a side lying position, a patient should be at a 30 degree angle with the bed unless contradicting with the patient's condition and other care needs that take priority.

• True

• False

A patient who can be taught should shift their weight every 30 minutes while sitting on a chair.

• True

• False

A stage 3 pressure injury is a partial thickness skin loss involving the epidermis and/ or dermis.

• True

• False

Stage 2 pressure injury may be extremely painful due to exposure of nerve ending.

• True

• False

Devices that suspend the heels can protect the heels from pressure.

• True

• False

This PI is...

• Stage 2

• Stage 3

• Stage 4

• Stage 5

A patient, 76 years old and weighs 85 lbs. Operation of both knees replacement just done. The patient is ordered pork congee diet daily. Select all the nursing intervention you will include in the patient's plan of care to prevent a pressure injury:

*You may choose multiple answers

• Consult a dietitian for diet modification to prevent pressure injury

• Encourage the patient to move out of bed as soon as possible if no contraindication.

• Keep linens and gowns dry and wrinkle free.

• Reassess the patient's PI risk

This PI is...

• Stage 1

• Stage 2

• Stage 3

• Unstageable