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Ch. 39 Pressure Injury Prevention and Care

Terms in this set (5)

An elderly patient who spends most of his waking hours in a chair is at risk for skin breakdown on his buttocks. What is the most appropriate action that the nurse should initiate with this patient?

Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position.

Teach the patient to change position with every television commercial.

Assess the outcomes of skin-focused interventions every 2 to 3 days.

To relieve pressure, place an inflatable ring on his chair.
Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. - Correct

Teach the patient to change position with every television commercial.

Assess the outcomes of skin-focused interventions every 2 to 3 days.

To relieve pressure, place an inflatable ring on his chair.
A patient has a pressure ulcer that contains necrotic tissue. Nursing care for this patient would be correct if which measure was taken to remove dead tissue from the wound bed?

Use of a wick to remove moisture from the decayed tissue

Use of hydrogen peroxide to loosen the necrotic tissue

Vigorous sterile scrubbing of the wound bed

A gentle topical method that removes dead tissue
Use of a wick to remove moisture from the decayed tissue

Use of hydrogen peroxide to loosen the necrotic tissue

Vigorous sterile scrubbing of the wound bed

A gentle topical method that removes dead tissue - Correct
A patient has nonreactive hyperemia. What would be expected to be included in the patient's immediate care?

An ordered increase in the amount of protein consumed

Use of the Braden Scale

Immediate transfer to a special pressure mattress

Padding around the area susceptible to breakdown
An ordered increase in the amount of protein consumed

Use of the Braden Scale - Correct

Immediate transfer to a special pressure mattress

Padding around the area susceptible to breakdown
An obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which strategies should the nurse who is caring for this patient include in his care?

Using a liftsheet and maintaining the head of the bed no higher than 30 degrees

Decreasing dietary protein intake and increasing his fluid intake to 2000 mL per day

Turning the patient every 4 hours and increasing caloric intake to maintain normal tissue status

Increasing the patient's vitamin and mineral intake and keeping the patient in high Fowler's position
Using a liftsheet and maintaining the head of the bed no higher than 30 degrees - Correct

Decreasing dietary protein intake and increasing his fluid intake to 2000 mL per day

Turning the patient every 4 hours and increasing caloric intake to maintain normal tissue status

Increasing the patient's vitamin and mineral intake and keeping the patient in high Fowler's position
The nurse is checking for discoloration on a patient who has darkly pigmented skin. The nurse would be administering appropriate care if which technique was used?

The nurse uses a gloved hand to feel for warmth or change in tissue texture.

The nurse uses a fluorescent light for the skin assessment.

The nurse places the patient in a 30-degree lateral position for the assessment.

The nurse checks for discoloration an hour after the patient is turned.
The nurse uses a gloved hand to feel for warmth or change in tissue texture. - Correct

The nurse uses a fluorescent light for the skin assessment.

The nurse places the patient in a 30-degree lateral position for the assessment.

The nurse checks for discoloration an hour after the patient is turned.
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