Pressure Injury Prevention and Assessment

A reddened area on a patient's sacrum remains non-blanchable after you press on it. What stage pressure injury is this?

• Stage I
• Stage II
• Stage III
• Stage IV

A wound has full-thickness skin loss with exposed muscle and bone. What stage pressure injury is this?

• Stage II
• Stage III
• Stage IV
• Unstageable

Which of the following is the best way to prevent pressure injuries in an immobile patient?

• Turn and reposition every two hours
• Apply antibiotic ointment daily
• Encourage fluid restriction
• Use restraints to prevent movement

You observe a wound covered completely by yellow slough, making it impossible to see the wound bed. What stage is this?

• Stage II
• Stage III
• Unstageable
• Deep tissue injury

What is the main purpose of the Braden Scale?

• To measure wound depth
• To assess risk for pressure injuries
• To document wound size
• To identify infection

Which tissue type in the wound bed indicates healing?

• Necrotic tissue
• Eschar
• Granulation tissue
• Slough

A patient has intact skin that appears purple and feels firm. What is this finding most consistent with?

• Stage I
• Stage II
• Unstageable
• Deep tissue injury

Which of the following interventions helps reduce friction and shear?

• Elevate the head of the bed 90 degrees
• Use a draw sheet to reposition
• Massage the reddened area
• Apply alcohol wipes to the area

Which patient is most at risk for developing a pressure injury?

• A patient on a low-air-loss mattress
• A patient who ambulates independently
• A patient who is incontinent and immobile
• A patient eating a high-protein diet

What nutrition recommendation best supports pressure injury prevention?

• Increase protein and fluid intake
• Limit carbohydrates
• Reduce calorie intake
• Avoid vitamin supplements