Practice Exam (Pressure Injuries) PDF

**Pressure Injuries/Skin Integrity:** **Question 1: Etiology of Pressure Injuries** A nurse is educating a group of caregivers about the etiology of pressure injuries. Which statement by a caregiver indicates the need for further teaching? A. \"Pressure injuries occur when oxygen supply to the ti...

**Pressure Injuries/Skin Integrity:** **Question 1: Etiology of Pressure Injuries** A nurse is educating a group of caregivers about the etiology of pressure injuries. Which statement by a caregiver indicates the need for further teaching? A. \"Pressure injuries occur when oxygen supply to the tissue is reduced.\"\ B. \"Shearing forces occur when the skin sticks to the bed, and the body moves in the opposite direction.\"\ C. \"Excessive diaphoresis can contribute to moisture-related pressure injuries.\"\ **D. \"Pressure injuries are only caused by external friction and not internal factors like perfusion.\"** **Correct Answer:** D\ **Rationale:** Pressure injuries result from both external factors (like friction and shearing) and internal factors (like poor oxygenation and perfusion). **Question 2: Staging of Pressure Injuries** A patient presents with a pressure injury that involves full-thickness tissue loss, exposure of bone, and the presence of slough and eschar. How should the nurse document this finding? A. Stage 1 pressure injury\ B. Stage 3 pressure injury\ C. Stage 4 pressure injury\ **D. Unstageable pressure injury** **Correct Answer:** D\ **Rationale:** The wound involves **full-thickness tissue loss**, **exposure of bone**, and the presence of **slough and eschar**. According to the **National Pressure Injury Advisory Panel (NPIAP)** guidelines, a pressure injury is classified as **unstageable** when the **wound bed is obscured** by **necrotic tissue** (slough or eschar). This prevents an accurate assessment of the extent of tissue damage and makes it impossible to determine the depth or stage of the injury until the necrotic tissue is removed. **Question 3: Using the Braden Scale** A patient with limited mobility has a Braden Scale score of 14 during an assessment. What should the nurse prioritize in the patient's care plan? A. Turning and repositioning every 4 hours.\ **B. Applying a pressure-relief mattress.**\ C. Using a heat lamp to warm the affected area.\ D. Encouraging ambulation without assistance. **Correct Answer:** B\ **Rationale:** A Braden score of 14 indicates a high risk of pressure injury, requiring interventions like pressure-relief devices to prevent skin breakdown. **Question 4: Nutrition and Wound Healing** Which intervention is most effective in promoting wound healing in a patient with a sacral pressure injury? A. Reducing caloric intake to minimize weight gain.\ B. Administering corticosteroids to control inflammation.\ **C. Increasing protein intake to support tissue repair.\ **D. Providing high-glucose meals for energy. **Correct Answer:** C\ **Rationale:** Adequate protein intake is critical for tissue repair and wound healing. **Question 5: Identifying Wound Healing Processes** A surgical wound with neatly approximated edges that undergoes a three-phase healing process is an example of which type of wound healing? **A. Primary intention**\ B. Secondary intention\ C. Tertiary intention\ D. Regeneration **Correct Answer:** A\ **Rationale:** Primary intention healing involves neatly approximated wound edges, as seen in surgical incisions. **Question 6: Managing Wound Infection** Which action should the nurse take first when managing a wound infection? A. Apply a moist dressing to the wound.\ B. Administer the prescribed antibiotic.\ **C. Obtain a wound culture using Levine's technique.**\ D. Cleanse the wound with a nontoxic solution. **Correct Answer:** C\ **Rationale:** A wound culture should be obtained before administering antibiotics to ensure appropriate treatment. **Question 7: Patient Education on Pressure Injury Prevention** A nurse is teaching a caregiver about pressure injury prevention. Which statement by the caregiver indicates effective learning? A. \"I should reposition my mother every 4 hours.\"\ B. \"Moisturizing the skin will increase the risk of pressure injuries.\"\ **C. \"I should use a lift sheet to move my mother up in bed.\"**\ D. \"Pressure-relief devices are only necessary if a sore develops.\" **Correct Answer:** C\ **Rationale:** Using a lift sheet prevents friction and shearing forces during repositioning, reducing the risk of pressure injuries. **Continued**: **Question 1: Pressure Injury Etiology** A nurse is educating a family member about the causes of pressure injuries. Which statement indicates the family member needs further teaching? A. \"Pressure injuries are caused by prolonged pressure on the skin and underlying tissues.\"\ B. \"Friction from moving the patient in bed can cause skin damage.\"\ C. \"Moisture, such as sweat or incontinence, can lead to skin breakdown.\"\ **D. \"A well-balanced diet has little effect on preventing pressure injuries.\"** **Correct Answer:** D\ **Rationale:** Adequate nutrition, particularly protein intake, is crucial in preventing and managing pressure injuries. **Question 2: Staging Pressure Injuries** A nurse assesses a patient's wound and notes partial-thickness skin loss involving the dermis and a pink wound bed. Which pressure injury stage does this describe? A. Stage 1\ **B. Stage 2\ **C. Stage 3\ D. Stage 4 **Correct Answer:** B\ **Rationale:** Stage 2 pressure injuries involve partial-thickness skin loss with a red or pink wound bed, without slough. **Question 3: Pressure Injury Risk Assessment** A patient has a Braden Scale score of 12 upon admission. What is the priority nursing intervention? A. Reassess skin condition every 8 hours.\ B. Use a high-protein diet to support skin integrity.\ **C. Turn and reposition the patient every 1-2 hours.**\ D. Document findings and continue routine care. **Correct Answer:** C\ **Rationale:** A score of 12 indicates high risk for pressure injuries, necessitating frequent repositioning to prevent skin breakdown. **Question 4: Wound Healing by Intention** A wound with wide, irregular margins and significant tissue loss is healing with granulation tissue and scar formation. This type of healing is classified as: A. Primary intention\ **B. Secondary intention**\ C. Tertiary intention\ D. Regeneration **Correct Answer:** B\ **Rationale:** Secondary intention occurs with wounds that have significant tissue loss, requiring granulation and scar formation. **Question 5: Managing Unstageable Wounds** A patient presents with a pressure injury covered by slough and eschar. What is the most appropriate nursing action? A. Document it as a Stage 4 injury and initiate debridement.\ **B. Leave the eschar intact if the area is dry and stable.**\ C. Begin wet-to-dry dressing changes immediately.\ D. Use enzymatic debridement agents to remove necrotic tissue. **Correct Answer:** B\ **Rationale:** Dry, stable eschar on areas like the heel serves as a protective barrier and should not be removed unless signs of infection are present. **Question 6: Wound Care Techniques** Before administering antibiotics for a suspected wound infection, the nurse should: **A. Collect a wound culture using Levine's technique.**\ B. Irrigate the wound with antiseptic solution.\ C. Apply a dressing to protect the wound from contamination.\ D. Educate the patient about the need for antibiotic therapy. **Correct Answer:** A\ **Rationale:** Cultures must be obtained before initiating antibiotic therapy to ensure the identification of the causative organism. **Question 7: Prevention of Pressure Injuries** Which intervention is most effective in preventing pressure injuries in a bedridden patient? A. Massage over bony prominences to improve circulation.\ **B. Use a moisture barrier cream for incontinent patients.**\ C. Keep the head of the bed elevated at 45 degrees.\ D. Apply heat packs to areas at risk for pressure injuries. **Correct Answer:** B\ **Rationale:** Moisture barrier creams prevent skin breakdown due to incontinence, a key factor in pressure injury prevention. **Question 8: Nutrition and Healing** A patient with a non-healing pressure injury has a dietary consult. Which intervention would most effectively promote healing? A. Reduce calorie intake to control weight.\ B. Provide meals high in carbohydrates for energy.\ **C. Increase protein intake to support tissue repair.**\ D. Eliminate fat from the diet to prevent obesity. **Correct Answer:** C\ **Rationale:** Protein is essential for tissue repair and healing in patients with pressure injuries.