RNRS 117- Pressure Injuries Pearson (Exam
I) With Complete Solutions
The nurse is providing teaching to the family caregiver of an older patient who
has become increasingly immobile at home.
Which instruction should the nurse provide to reduce the patient's risk of
developing a pressure injury?
Massage the bony prominences daily.
Monitor the diet to ensure adequate intake of proteins and calories.
Use an alcohol-based sanitizer to clean the skin after incidences of
incontinence.
Help the patient to move at least every 4 hours. - ANSWER Monitor the diet to
ensure adequate intake of proteins and calories.
The nurse identifies that a patient with decreased mental status is at risk for a
pressure injury.
Which action should the nurse take to maintain skin hygiene and prevent a
pressure injury?
Applying lotion to moist skin after bathing
Monitoring the skin once a week during bathing
Massaging bony prominences during bathing
Using hot water and mild soap during bathing - ANSWER Applying lotion to moist
skin after bathing
The nurse is caring for a patient with limited mobility.
Which action should the nurse take to prevent a skin injury caused by friction?
Avoiding use of a draw sheet when repositioning the patient
Placing the patient in the prone position
Sprinkling baby powder on the sheets to keep the skin dry
Elevating the head of the bed to a 60-degree angle - ANSWER Placing the patient
in the prone position
A patient with a stage 3 pressure injury reports pain at the site which has
developed a yellow-white exudate on the wound bed.
Which laboratory test should the nurse anticipate being prescribed?
Hemoglobin and hematocrit
Arteral blood gas (ABG)
Serum protein
, Complete blood count - ANSWER Complete blood count
A patient with a pressure injury on the sacrum has obvious necrosis of
subcutaneous tissue.
For which pressure stage should the nurse plan care for this patient?
Stage 1
Stage 2
Stage 3
Stage 4 - ANSWER Stage 3
A patient develops paraplegia after a motor vehicle crash.
Which information should the nurse include when teaching the patient to prevent
pressure injuries?
Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help
promote circulation
Use the trapeze to help slide up to the head of the bed
Baby powder can be applied to bony prominences to prevent skin breakdown
Reposition every 4 hours if using a special mattress - ANSWER Slight weight
shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation
A patient at risk for a pressure injury responds to verbal commands, has no
sensory deficits, has moist skin, ambulates occasionally, makes slight position
changes, and eats approximately 50% of each meal.
Which Braden scale score should the nurse identify for this patient?
16
6
21
12 - ANSWER 16
The nurse is caring for a patient with a stage 1 pressure injury to the sacrum.
Which product should the nurse suggest to help increase the blood supply to the
skin of this pressure injury?
Vacuum-assisted closure
Transparent dressing
Granulex
Hydrogel dressing - ANSWER Granulex
A patient has an area of eschar within a healing wound.
Which type of debridement should the nurse expect to be ordered because it
does not damage healthy and healing tissue within a pressure injury?
Chemical
I) With Complete Solutions
The nurse is providing teaching to the family caregiver of an older patient who
has become increasingly immobile at home.
Which instruction should the nurse provide to reduce the patient's risk of
developing a pressure injury?
Massage the bony prominences daily.
Monitor the diet to ensure adequate intake of proteins and calories.
Use an alcohol-based sanitizer to clean the skin after incidences of
incontinence.
Help the patient to move at least every 4 hours. - ANSWER Monitor the diet to
ensure adequate intake of proteins and calories.
The nurse identifies that a patient with decreased mental status is at risk for a
pressure injury.
Which action should the nurse take to maintain skin hygiene and prevent a
pressure injury?
Applying lotion to moist skin after bathing
Monitoring the skin once a week during bathing
Massaging bony prominences during bathing
Using hot water and mild soap during bathing - ANSWER Applying lotion to moist
skin after bathing
The nurse is caring for a patient with limited mobility.
Which action should the nurse take to prevent a skin injury caused by friction?
Avoiding use of a draw sheet when repositioning the patient
Placing the patient in the prone position
Sprinkling baby powder on the sheets to keep the skin dry
Elevating the head of the bed to a 60-degree angle - ANSWER Placing the patient
in the prone position
A patient with a stage 3 pressure injury reports pain at the site which has
developed a yellow-white exudate on the wound bed.
Which laboratory test should the nurse anticipate being prescribed?
Hemoglobin and hematocrit
Arteral blood gas (ABG)
Serum protein
, Complete blood count - ANSWER Complete blood count
A patient with a pressure injury on the sacrum has obvious necrosis of
subcutaneous tissue.
For which pressure stage should the nurse plan care for this patient?
Stage 1
Stage 2
Stage 3
Stage 4 - ANSWER Stage 3
A patient develops paraplegia after a motor vehicle crash.
Which information should the nurse include when teaching the patient to prevent
pressure injuries?
Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help
promote circulation
Use the trapeze to help slide up to the head of the bed
Baby powder can be applied to bony prominences to prevent skin breakdown
Reposition every 4 hours if using a special mattress - ANSWER Slight weight
shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation
A patient at risk for a pressure injury responds to verbal commands, has no
sensory deficits, has moist skin, ambulates occasionally, makes slight position
changes, and eats approximately 50% of each meal.
Which Braden scale score should the nurse identify for this patient?
16
6
21
12 - ANSWER 16
The nurse is caring for a patient with a stage 1 pressure injury to the sacrum.
Which product should the nurse suggest to help increase the blood supply to the
skin of this pressure injury?
Vacuum-assisted closure
Transparent dressing
Granulex
Hydrogel dressing - ANSWER Granulex
A patient has an area of eschar within a healing wound.
Which type of debridement should the nurse expect to be ordered because it
does not damage healthy and healing tissue within a pressure injury?
Chemical
