WND 580 EVALUATION EXAMS ANSWERS AND
QUESTIONS SET A+
✔✔You have a patient with significant COPD who needs the HOB elevated most of the
time, diaphoretic due to fevers, and Braden score of 9, which of the following would be
the BEST pressure redistribution surface?
a. Surface with an alternating pressure feature.
b. Surface with a low shear cover and low air loss feature.
c. Surface with a viscoelastic foam feature.
d. Surface with air fluidize feature. - ✔✔b. Surface with a low shear cover and low air
loss feature.
✔✔You are called to the ICU to evaluate a critically ill patient who is hemodynamically
unstable. Which of the following is considered an evidence-based recommendation for
this population?
a. Position on the right side and use pillows or wedges to create small lateral shifts of 15
degrees.
b. Position patient primarily on the left lateral position and change position with 30-
degree lateral shifts every 2 hours.
c. Ask staff not to change the position of the patient if unable to stabilize vital signs after
2 minutes.
d. Place the patient at a 90-degree side-lying tilt with the use of pillows and wedges. -
✔✔a. Position on the right side and use pillows or wedges to create small lateral shifts
of 15 degrees.
✔✔ Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3
pressure injury on her coccyx with undermining. Which of the following risk factors is
most responsible for undermining in the pressure injury?
a. Shear from having the head of bed elevated to 45 degrees.
b. Friction from her turning from side to side.
c. Local infection in the wound.
, d. Excess moisture in the wound bed. - ✔✔a. Shear from having the head of bed
elevated to 45 degrees.
✔✔A patient with paraplegia is in the wound clinic to have a new seating surface re-
evaluated. You notice a serous fluid filled blister on the left heel which you document as
a pressure injury in what Stage?
a. Stage 1.
b. Stage 2.
c. Stage 3.
d. Stage 4. - ✔✔b. Stage 2.
✔✔The care plan for the patient with a pressure risk assessment score (Braden Scale)
of 9 and on a therapeutic support surface should always include:
a. Maintaining HOB at 45 degrees or less.
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
c. Use an artificial sheepskin under the coccyx to prevent shear.
d. Avoid the use of absorbent under pads in patients with incontinence. - ✔✔b.
Reposition the patient every 2-4 hours depending upon tissue tolerance.
✔✔Mr. Lee was found lying at home on the floor. Upon admission, he has an intact,
nonblanchable, persistent purple discoloration over the coccyx. Which describes the
classification of his pressure injury?
a. Deep tissue pressure injury.
b. Stage 1 pressure injury.
c. Unstageable.
d. Stage 3 pressure injury. - ✔✔a. Deep tissue pressure injury.
✔✔Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath.
Which of the following is considered a potential PRIMARY etiologic factor in the
development of a pressure injury for this patient?
a. Shear force
b. Short-term pressure force
c. Friction force
d. Presence of a medical device - ✔✔a. Shear force
✔✔Which area of the body is the MOST difficult to offload using a pressure
redistribution surface?
a. Sacrum.
b. Occiput.
c. Trochanter.
QUESTIONS SET A+
✔✔You have a patient with significant COPD who needs the HOB elevated most of the
time, diaphoretic due to fevers, and Braden score of 9, which of the following would be
the BEST pressure redistribution surface?
a. Surface with an alternating pressure feature.
b. Surface with a low shear cover and low air loss feature.
c. Surface with a viscoelastic foam feature.
d. Surface with air fluidize feature. - ✔✔b. Surface with a low shear cover and low air
loss feature.
✔✔You are called to the ICU to evaluate a critically ill patient who is hemodynamically
unstable. Which of the following is considered an evidence-based recommendation for
this population?
a. Position on the right side and use pillows or wedges to create small lateral shifts of 15
degrees.
b. Position patient primarily on the left lateral position and change position with 30-
degree lateral shifts every 2 hours.
c. Ask staff not to change the position of the patient if unable to stabilize vital signs after
2 minutes.
d. Place the patient at a 90-degree side-lying tilt with the use of pillows and wedges. -
✔✔a. Position on the right side and use pillows or wedges to create small lateral shifts
of 15 degrees.
✔✔ Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3
pressure injury on her coccyx with undermining. Which of the following risk factors is
most responsible for undermining in the pressure injury?
a. Shear from having the head of bed elevated to 45 degrees.
b. Friction from her turning from side to side.
c. Local infection in the wound.
, d. Excess moisture in the wound bed. - ✔✔a. Shear from having the head of bed
elevated to 45 degrees.
✔✔A patient with paraplegia is in the wound clinic to have a new seating surface re-
evaluated. You notice a serous fluid filled blister on the left heel which you document as
a pressure injury in what Stage?
a. Stage 1.
b. Stage 2.
c. Stage 3.
d. Stage 4. - ✔✔b. Stage 2.
✔✔The care plan for the patient with a pressure risk assessment score (Braden Scale)
of 9 and on a therapeutic support surface should always include:
a. Maintaining HOB at 45 degrees or less.
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
c. Use an artificial sheepskin under the coccyx to prevent shear.
d. Avoid the use of absorbent under pads in patients with incontinence. - ✔✔b.
Reposition the patient every 2-4 hours depending upon tissue tolerance.
✔✔Mr. Lee was found lying at home on the floor. Upon admission, he has an intact,
nonblanchable, persistent purple discoloration over the coccyx. Which describes the
classification of his pressure injury?
a. Deep tissue pressure injury.
b. Stage 1 pressure injury.
c. Unstageable.
d. Stage 3 pressure injury. - ✔✔a. Deep tissue pressure injury.
✔✔Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath.
Which of the following is considered a potential PRIMARY etiologic factor in the
development of a pressure injury for this patient?
a. Shear force
b. Short-term pressure force
c. Friction force
d. Presence of a medical device - ✔✔a. Shear force
✔✔Which area of the body is the MOST difficult to offload using a pressure
redistribution surface?
a. Sacrum.
b. Occiput.
c. Trochanter.
