SKIN ANATOMY , PRESSURE INJURY STAGING , BRADEN
SCALE & DRESSING SELECTIONS COMPLETE ACCURATE
EXAM REAL QUESTIONS AND ACCURATE DETAILED
ANSWERS WITH RATIONALES 100% CORRECT VERIFIED
SOLUTIONS LATEST UPDATE 2026 EDITION |
GUARANTEED SUCCESS A+ || FULL REVISED EXAM \Emory
University || NRSG 426
,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
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 position changes is compromised. His risk for heel ulcer
development is high as well. Floating the heels off of all surfaces is a
high priority for his care as well.
, L.M. is a 51 year old male patient with COPD, CHF, Type II Diabetes
(poorly controlled), diabetic neuropathy, controlled atrial fib, and 50
year pack history.
He has bilateral foot ulcers which are being managed with Negative
Pressure Wound Therapy (NPWT); heel elevation boots are being used
consistently.
L.M. has no other skin breakdown at this time. Braden score = 17. He is on
a constant low pressure (CLP) pressure redistributing foam hospital
mattress.
What is your evaluation of this surface?
A. He should be placed on an alternating pressure surface.
B. He needs a surface with low air loss feature for his bed but not his
chair.
C. He needs surfaces with a low air loss feature for his wheelchair and
his bed.
D. He is on the appropriate pressure redistribution surface.
D