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concept in nursing 2

Pressure ulcers

QuestionAnswer
The nurse is evaluating a patient’s risk for developing a pressure ulcer. Which patient characteristics does the nurse consider? -Age -Activity -General health
The nurse is caring for a patient with a pressure ulcer determined to be unstageable. What characteristics would the nurse expect? Eschar is covering wound bed
The charge nurse is leading a unit discussion on pressure ulcers. Which statements should the nurse include? -“The risk is influenced by nutrition and activity.” -“People with an inability to communicate are at high risk.” -“They can be prevented by relieving pressure on the affected areas.”
The wound care nurse assesses a group of patients on the unit. Which patient is at risk of developing a pressure ulcer? A patient with a spinal cord injury.
The patient on anticoagulant therapy has a pressure ulcer on the right foot that has a foul odor to the drainage. The patient has good peripheral pulses. The nurse anticipates the health care provider will prescribe which interventions? -Obtain a wound drainage specimen for culture and sensitivity -Cushion foot to prevent contact between the ulcer and the bed -Have a dietitian evaluate nutrition needs and create a new diet plan
The nurse is caring for an immobile older adult who is at high risk for pressure ulcer formation. Which measure is important to prevent pressure ulcer formation in this patient? Provide foam material for the patient’s heels
The nurse assesses a patient with diabetes mellitus who has a pressure ulcer on the heel. Which intervention should the nurse question while the patient is on bedrest? Application of bilateral knee-high compression socks
A nurse is reviewing the electronic medical record of a patient with a stage 2 pressure ulcer to the iliac crest and notices the following entry: “Wound bed is pink with noticeable slough --
It measures 2 cm * 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing.” Which data is missing from the documentation entry? Type of drainage
The nurse is caring for patient with paraplegia. Which nursing action is important for preventing pressure ulcer formation in this patient? Ask patient to participate in repositioning whenever possible
Which information about pressure ulcer formation should be provided by the nurse to a patient with decreased mobility? -“Ambulate to the restroom frequently.” -“Place pillows between your legs when sleeping.” -“Shift your weight every 60 minutes while sitting down.”
Created by: Lightnning54
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