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The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention requires revision?
The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention requires revision?
The nurse is monitoring a patient's stage 3 pressure injury for healing during treatment. Which finding demonstrates improvement?
The nurse is monitoring a patient's stage 3 pressure injury for healing during treatment. Which finding demonstrates improvement?
The nurse is providing care for a patient with limited mobility. The nurse notes that the head of the patient's bed is frequently at 45 degrees of elevation and the patient is slouched in the bed. What action should the nurse take first?
The nurse is providing care for a patient with limited mobility. The nurse notes that the head of the patient's bed is frequently at 45 degrees of elevation and the patient is slouched in the bed. What action should the nurse take first?
The nurse is providing care for a patient who has a stage 4 pressure injury that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which finding should the nurse communicate to the registered nurse(RN)immediately?
The nurse is providing care for a patient who has a stage 4 pressure injury that is 2 cm in diameter and 2 cm deep. Bone is visible in the wound. Which finding should the nurse communicate to the registered nurse(RN)immediately?
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The nurse is providing care for a patient with an open pressure injury on the right hip. The bed of the wound is covered with thick, black eschar and the tissue around the wound is red and warm to the touch. What should the nurse prepare for when the health-care provider(HCP)arrives?
The nurse is providing care for a patient with an open pressure injury on the right hip. The bed of the wound is covered with thick, black eschar and the tissue around the wound is red and warm to the touch. What should the nurse prepare for when the health-care provider(HCP)arrives?
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A patient is admitted with a recent surgical wound that is infected and exhibits an open suture line. The HCP prescribes negative pressure wound therapy(NPWT). How should the nurse prepare for treatment?
A patient is admitted with a recent surgical wound that is infected and exhibits an open suture line. The HCP prescribes negative pressure wound therapy(NPWT). How should the nurse prepare for treatment?
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A patient comes into the HCP's office and reports a rash. The nurse notices a red rash on the patient's chest, back, arms and legs. The patient describes an intense itching. What question should the nurse ask?
A patient comes into the HCP's office and reports a rash. The nurse notices a red rash on the patient's chest, back, arms and legs. The patient describes an intense itching. What question should the nurse ask?
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A patient in the emergency department has bright red edematous plaques along an uneven line that runs from under the right arm toward the chest. The patient states that the breakout was sudden and is very painful. Which information does the nurse need to obtain first?
A patient in the emergency department has bright red edematous plaques along an uneven line that runs from under the right arm toward the chest. The patient states that the breakout was sudden and is very painful. Which information does the nurse need to obtain first?
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The nurse works in a clinic that specializes in the care of patients diagnosed with psoriasis. Which patient is most concerning?
The nurse works in a clinic that specializes in the care of patients diagnosed with psoriasis. Which patient is most concerning?
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The nurse in a school clinic is aware of an unusually high incidence of cold sores among the student population. What action can the nurse take to control the spread?
The nurse in a school clinic is aware of an unusually high incidence of cold sores among the student population. What action can the nurse take to control the spread?
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The community nurse is working with a family who has had multiple infestations of pediculosis capitis over a period of several months. Which comment by the parent indicates understanding of the instructions
The community nurse is working with a family who has had multiple infestations of pediculosis capitis over a period of several months. Which comment by the parent indicates understanding of the instructions
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The nurse is assisting with preparation for cryosurgery for a patient diagnosed with a lentigo maligna melanoma lesion on the forehead. Which information will the nurse provide in preparation for surgery
The nurse is assisting with preparation for cryosurgery for a patient diagnosed with a lentigo maligna melanoma lesion on the forehead. Which information will the nurse provide in preparation for surgery
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The nurse is preparing to begin a position in an extended-care facility. The RN shares that the administration is interested in research that guides the skin care of the residents. Which information does the nurse discover about best practices?
The nurse is preparing to begin a position in an extended-care facility. The RN shares that the administration is interested in research that guides the skin care of the residents. Which information does the nurse discover about best practices?
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The nurse is providing care for a patient with an open pressure injury, which exhibits the manifestations of an infection. The HCP prescribes wound cleansing with normal saline at a pressure of 4 to 15 pounds per square inch. Which method of cleansing should the nurse use?
The nurse is providing care for a patient with an open pressure injury, which exhibits the manifestations of an infection. The HCP prescribes wound cleansing with normal saline at a pressure of 4 to 15 pounds per square inch. Which method of cleansing should the nurse use?
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The nurse is assisting at a community health fair by performing skin checks. Which characteristic is less likely to occur in a participant who has dark skin?
The nurse is assisting at a community health fair by performing skin checks. Which characteristic is less likely to occur in a participant who has dark skin?
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The nurse at an HCP's office is interviewing a patient presenting with a skin infection. Which question should the nurse ask first?
The nurse at an HCP's office is interviewing a patient presenting with a skin infection. Which question should the nurse ask first?
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A patient with an infected skin lesion is prescribed oral antibiotics, daily dressing changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which patient statement to the nurse is most concerning?
A patient with an infected skin lesion is prescribed oral antibiotics, daily dressing changes with topical antibiotic ointment, and acetaminophen with codeine for pain. Which patient statement to the nurse is most concerning?
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A patient is diagnosed with dermatomycosis. Which statement by the patient gives the nurse an idea of where the infection was acquired?
A patient is diagnosed with dermatomycosis. Which statement by the patient gives the nurse an idea of where the infection was acquired?
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The nurse is providing care for a patient who is immobile and being treated for diabetes mellitus and a urinary tract infection. Which intervention is included in a plan of care to prevent pressure injuries in this patient? Select all apply
The nurse is providing care for a patient who is immobile and being treated for diabetes mellitus and a urinary tract infection. Which intervention is included in a plan of care to prevent pressure injuries in this patient? Select all apply
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The nurse is completing the Braden scale to predict risk for pressure ulcer development with a patient on bedrest. Which findings does the nurse score as increasing this patient's risk? (Select all that apply)
The nurse is completing the Braden scale to predict risk for pressure ulcer development with a patient on bedrest. Which findings does the nurse score as increasing this patient's risk? (Select all that apply)
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Study Notes
Pressure Injury Prevention
- Intervention Requiring Revision: The nurse should revise the intervention that relies solely on turning the patient every 2 hours. Turning alone is ineffective. Other interventions like repositioning, pressure-relieving devices, and skin inspection are crucial to prevent pressure injuries.
- Stage 3 Pressure Injury Improvement: The nurse should monitor for wound bed granulation tissue growth. Granulation tissue is a sign of healing and indicates improvement in a stage 3 pressure injury.
Patient with Limited Mobility
- Action to Take First: The nurse should reposition the patient using a lift sheet or other assistive device. This will help prevent further injury and discomfort while ensuring safety for both the nurse and the patient.
Stage 4 Pressure Injury
- Finding to Report Immediately: The nurse should immediately notify the registered nurse (RN) if the patient presents with a fever or sudden increase in drainage or odor. These symptoms indicate a potential wound infection, requiring rapid intervention.
Open Pressure Injury on Hip
- Preparation for HCP Arrival: The nurse should prepare for a surgical debridement. This involves surgically removing the thick, black eschar to allow for proper wound assessment and healing.
Negative Pressure Wound Therapy
- Preparation for Treatment: The nurse should gather supplies, including negative pressure wound therapy equipment and sterile wound dressings. Ensuring the wound is properly prepped and protected is essential for NPWT application.
Patient with Rash
- Question to Ask: The nurse should ask the patient about recent medication changes. This is critical to determine if the rash may be an allergic reaction to a new medication.
Patient with Edematous Plaques
- Information to Obtain First: The nurse should obtain the patient's allergy history. The patient's sudden, painful breakout could be a manifestation of an allergic reaction, leading to the need for immediate medical intervention.
Patient with Psoriasis
- Most Concerning Patient: The nurse should prioritize the patient displaying new onset joint pain or swelling. This could indicate a possible psoriasis arthritis, a more serious condition with potentially debilitating symptoms.
Cold Sores in School
- Action to Take: The nurse should educate students about the importance of hand hygiene and avoiding direct contact with sores. Emphasizing these practices can significantly reduce the spread of cold sores within the school environment.
Pediculosis Capitis
- Understanding of Instructions: The nurse identifies that the parent understands the instructions when they mention the importance of thorough washing and heat-treating bedding and clothing.
Cryosurgery
- Information to Provide: The nurse should explain that cryosurgery is a painless procedure that involves freezing the lesion, and the area may be red or swollen for a few weeks.
Skin Care for Residents
- Best Practices: The nurse discovers that the best practice for resident skin care in an extended care facility involves routine emollient use, proper hygiene, and keeping residents well-hydrated.
Open Pressure Injury with Infection
- Cleansing Method: The nurse should cleanse the wound with normal saline using a pulsatile lavage. This technique effectively removes debris and allows for optimal cleansing while maintaining the desired pressure range.
Skin Checks
- Characteristic Less Likely in Dark Skin: Less common skin cancers in individuals with dark skin may present as more subtle or ambiguous changes, making accurate detection challenging. It is crucial to emphasize that individuals with dark skin should regularly monitor their skin for any suspicious changes.
Skin Infection
- Question to Ask First: The nurse should ask about any recent contact with other individuals with skin infections. This question helps determine possible sources of infection and assists in identifying potential risk factors.
Infected Skin Lesion
- Most Concerning Statement: The nurse should be concerned if the patient states they have been experiencing difficulty breathing. This could be an indication of a severe allergic reaction to the antibiotic medication.
Dermatomycosis
- Information about Infection Acquisition: The nurse should recognize that a patient disclosing they recently visited a public swimming pool or used a communal shower potentially acquired dermatomycosis from these environments.
Pressure Injury Prevention for Immobile Diabetic Patient
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Interventions to Prevent Pressure Injuries:
- Regular skin inspection: Visually examining the skin for any signs of redness, warmth, or change in texture is crucial to identifying early pressure injury development.
- Frequent repositioning: Changing the patient's position every two hours, or more frequently if needed, helps distribute pressure and reduce the risk of pressure injury formation.
- Proper body alignment: Ensuring proper body alignment reduces pressure points and contributes to effective pressure injury prevention.
- Use of pressure-relieving devices: Employing devices like pressure-relieving mattresses or cushions helps reduce pressure throughout the body, especially in areas prone to pressure injuries.
- Hydration and nutrition: Maintaining adequate hydration and nutrition is essential to promote overall health and tissue integrity, which can contribute to pressure injury resistance.
Braden Scale
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Findings Increasing Risk for Pressure Ulcer Development:
- Sensory perception: Impaired sensory perception, such as difficulty feeling pain or pressure, significantly increases the risk of pressure ulcers.
- Moisture: Excessive perspiration or incontinence can lead to skin maceration and increased vulnerability to pressure injury development.
- Activity: Limited mobility, bed rest, or decreased activity restricts movement and increases pressure points, making a patient more susceptible to pressure ulcers.
- Nutrition: Poor nutritional status, malnutrition, or inadequate protein intake can compromise skin integrity and increase the risk of pressure ulcers.
- Friction and shear: Frequent repositioning and friction against surfaces can damage skin and contribute to pressure ulcer development.
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Description
This quiz focuses on the critical interventions needed to prevent pressure injuries in long-term care facilities. It evaluates the effectiveness of different nursing strategies and identifies potential revisions to current practices. Ideal for nursing students and healthcare professionals.
