WND 580 - Module 2 Quiz N N N N N
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3 pressure injury
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on her coccyx with undermining. Which of the following risk factors is most responsible for
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undermining in the pressure injury?
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a. Shear from having the head of bed elevated to 45 degrees.
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b. Friction from her turning from side to side.
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c. Local infection in the wound.
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d. Excess moisture in the wound bed. - CORRECT ANSWER-a. Shear from having the head of bed
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elevated to 45 degrees.
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A patient with paraplegia is in the wound clinic to have a new seating surface re-evaluated. You
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notice a serous fluid filled blister on the left heel which you document as a pressure injury in
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what Stage?
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a. Stage 1.
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b. Stage 2.
N N
c. Stage 3.
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d. Stage 4. - CORRECT ANSWER-b. Stage 2.
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The care plan for the patient with a pressure risk assessment score (Braden Scale) of 9 and on a
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therapeutic support surface should always include:
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a. Maintaining HOB at 45 degrees or less.
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b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
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, c. Use an artificial sheepskin under the coccyx to prevent shear.
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d. Avoid the use of absorbent under pads in patients with incontinence. - CORRECT ANSWER-b.
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Reposition the patient every 2-4 hours depending upon tissue tolerance.
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Mr. Lee was found lying at home on the floor. Upon admission, he has an intact, nonblanchable,
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persistent purple discoloration over the coccyx. Which describes the classification of his
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pressure injury?
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a. Deep tissue pressure injury.
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b. Stage 1 pressure injury.
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c. Unstageable.
N
d. Stage 3 pressure injury. - CORRECT ANSWER-a. Deep tissue pressure injury.
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Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath. Which of the
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following is considered a potential PRIMARY etiologic factor in the development of a pressure
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injury for this patient?
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a. Shear force
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b. Short-term pressure force
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c. Friction force
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d. Presence of a medical device - CORRECT ANSWER-a. Shear force
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Which area of the body is the MOST difficult to offload using a pressure redistribution surface?
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a. Sacrum.
N
b. Occiput.
N
c. Trochanter.
N
Mrs. Canfield is intubated with her HOB elevated 45 degrees. She has a Stage 3 pressure injury
N N N N N N N N N N N N N N N N
on her coccyx with undermining. Which of the following risk factors is most responsible for
N N N N N N N N N N N N N N N
undermining in the pressure injury?
N N N N N
a. Shear from having the head of bed elevated to 45 degrees.
N N N N N N N N N N N
b. Friction from her turning from side to side.
N N N N N N N N
c. Local infection in the wound.
N N N N N
d. Excess moisture in the wound bed. - CORRECT ANSWER-a. Shear from having the head of bed
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elevated to 45 degrees.
N N N N
A patient with paraplegia is in the wound clinic to have a new seating surface re-evaluated. You
N N N N N N N N N N N N N N N N
notice a serous fluid filled blister on the left heel which you document as a pressure injury in
N N N N N N N N N N N N N N N N N N
what Stage?
N N
a. Stage 1.
N N
b. Stage 2.
N N
c. Stage 3.
N N
d. Stage 4. - CORRECT ANSWER-b. Stage 2.
N N N N NN N N
The care plan for the patient with a pressure risk assessment score (Braden Scale) of 9 and on a
N N N N N N N N N N N N N N N N N N
therapeutic support surface should always include:
N N N N N N
a. Maintaining HOB at 45 degrees or less.
N N N N N N N
b. Reposition the patient every 2-4 hours depending upon tissue tolerance.
N N N N N N N N N N
, c. Use an artificial sheepskin under the coccyx to prevent shear.
N N N N N N N N N N
d. Avoid the use of absorbent under pads in patients with incontinence. - CORRECT ANSWER-b.
N N N N N N N N N N N N N NN
Reposition the patient every 2-4 hours depending upon tissue tolerance.
N N N N N N N N N N
Mr. Lee was found lying at home on the floor. Upon admission, he has an intact, nonblanchable,
N N N N N N N N N N N N N N N N
persistent purple discoloration over the coccyx. Which describes the classification of his
N N N N N N N N N N N N
pressure injury?
N N
a. Deep tissue pressure injury.
N N N N N
b. Stage 1 pressure injury.
N N N N
c. Unstageable.
N
d. Stage 3 pressure injury. - CORRECT ANSWER-a. Deep tissue pressure injury.
N N N N N N NN N N N N
Mr. Peterson likes the head of the bed at 60 degrees due to shortness of breath. Which of the
N N N N N N N N N N N N N N N N N N
following is considered a potential PRIMARY etiologic factor in the development of a pressure
N N N N N N N N N N N N N N
injury for this patient?
N N N N
a. Shear force
N N N
b. Short-term pressure force
N N N
c. Friction force
N N
d. Presence of a medical device - CORRECT ANSWER-a. Shear force
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Which area of the body is the MOST difficult to offload using a pressure redistribution surface?
N N N N N N N N N N N N N N N
a. Sacrum.
N
b. Occiput.
N
c. Trochanter.
N
