ACTUAL CORRECT QUESTIONS AND VERIFIED
DETAILED ANSWERS |CURRENTLY TESTING
QUESTIONS AND SOLUTIONS|ALREADY
GRADED A+|NEWEST |BRAND NEW
VERSION!!|JUST RELEASED
How many days does it normally take for a deep tissue pressure injury (DTPI) to evolve? (L3)
A. 1-2 days
B. 3-7 days
C. >7 days
B
As long as tissue interface pressures are maintained at a level below 25 mmHg, the patient
will not develop a pressure injury. (L3)
True or False
False
Failure to closely inspect skin on admission can result in lost revenues and increased
liability. (L3)
True or False
True
Tissue ischemia causes discomfort, which prompts a healthy individual to change
positions and offload the affected area. (L3)
True or False
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,True
Match each risk factor to skin loss caused by external factors. (L3)
A. Skin Tears
B. MARSI
1. dependency on others for ADLs
2. purpuric lesions
3. chronic or critical illness
4. cytotoxic therapy (chemo or radiation)
5. intervention-intense areas (ED, ICU, OR, etc)
6. thin, fragile skin d/t drugs, malnutrition, or dermatologic conditions
A - 1, 2, 3
B - 4, 5, 6
T.W. is an 81 year old male in acute care setting
Admission diagnosis: Right pleural effusion and broncho-pleural fistula.
Pertinent Medical History: multiple myeloma and cardiac issues.Current Braden Score =
12. His current weight is 200lbs.Albumin: 2.0. Nutrition consult ordered with a calorie
count.Frequently incontinent of loose stools and Braden moisture subscale score is 1.
Chest tube on the right side of his chest makes it painful to turn; minimally assists with
turn/position changes. He has an unstageable pressure ulcer on his sacral area which is
difficult to offload.
The best support surface for him is:
A. CLP with low air loss feature
B. CLP: 4" high density foam overlay
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, C. Bariatric surface with reduced friction/shear surface covering
D. Alternating pressure (AP) surface
A - This patient has moisture, nutrition, activity, and mobility issues which places him at
high risk for breakdown. The head of bed will likely be raised to help improve his respiratory
function, causing increased pressure and potential for friction/shear to the sacro-
coccygeal area.
Utilizing the subscales of the Braden Risk Assessment Tool will help in determining the
correct support surface. In this patient the moisture subscale score indicates a need for
low air loss.
R.H. was admitted to a long term acute care (LTAC) hospital.
Admission Diagnosis & Status: Chronic Obstructive Pulmonary Disease (COPD) with gram+
bacteremia.
Nine (9) days after admission, he developed respiratory failure; was intubated; placed on
mechanical ventilation and a Propofol infusion for sedation. Three days later his
assessment reveals generalized edema, and 2 new stage 2 pressure injuries on the sacrum
and right scapula. His Braden score is now 9 with a moisture subscale score of 2.
What is the best support surface for his needs?
A. CLP: 4" high density foam overlay
B. Alternating pressure (AP) surface
C. CLP with air fluidized feature
D. CLP with low air loss feature
D - Technically he has only one turning surface affected, but he is at high risk for sacro-
coccygeal skin breakdown due to the poor respiratory status--indicating the need for a
higher level of support. PEG placement and tube feedings will require head of bed elevation
as well. Given the vent and paralytic medications, his ability to acknowledge/ participate in
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