1. The nurse is caring for a patient who is at risk for skin impairment. The patient
is able to sit up in a chair. The nurse includes this intervention in the plan of care.
How long should the nurse schedule the patient to sit in the chair?
a. At least 3 hours
b. Less than 2 hours
c. No longer than 30 minutes
d. As long as the patient remains comfortable
ANS: B
When patients are able to sit up in a chair, make sure to limit the amount of time to
2 hours or less. The chair sitting time should be individualized. In the sitting
position, pressure on the ischial tuberosities is greater than in a supine position.
Utilize foam, gel, or an air cushion to distribute weight. Sitting for longer than 2
hours can increase the chance of ischemia.
2. The nurse is caring for a patient who is immobile and is at risk for skin
impairment. The plan of care includes turning the patient. Which is the best
method for repositioning the patient?
a. Place the patient in a 30-degree supine position.
b. Utilize a transfer device to lift the patient.
c. Elevate the head of the bed 45 degrees.
,d. Slide the patient into the new position.
ANS: B
When repositioning the patient, obtain assistance and utilize a transfer device to
lift rather than drag the patient. Sliding the patient into the new position will
increase friction. The patient should be placed in a 30- degree lateral position, not
a supine position. The head of the bed should be elevated less than 30 degrees to
prevent pressure ulcer development from shearing forces.
3. A nurse is assigned most of the patients with pressure ulcers. The nurse leaves
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, the pressure ulcer open to air and does not apply a dressing. To which patient did
the nurse provide care?
a. A patient with a clean Stage I
b. A patient with a clean Stage II
c. A patient with a clean Stage III
d. A patient with a clean Stage IV
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14
days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be
utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium
alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with
foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An
unstageable wound covered with eschar should utilize a dressing of adherent film or
gauze with an ordered solution of enzymes.
4. The nurse is caring for a patient with a wound. The patient appears anxious
as the nurse is preparing to change the dressing. Which action should the nurse
take?
a. Turn on the television.
b. Explain the procedure.
c. Tell the patient “Close your eyes.”
d. Ask the family to leave the room.
ANS: B
Explaining the procedure educates the patient regarding the dressing change
and involves him in the care, thereby allowing the patient some control in
decreasing anxiety. Telling the patient to close the eyes and turning on the
television are distractions that do not usually decrease a patient’s anxiety. If the
family is a support system, asking support systems to leave the room can
actually increase a patient’s anxiety.
5. The nurse is cleansing a wound site. As the nurse administers the procedure,
which intervention should be included?
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is able to sit up in a chair. The nurse includes this intervention in the plan of care.
How long should the nurse schedule the patient to sit in the chair?
a. At least 3 hours
b. Less than 2 hours
c. No longer than 30 minutes
d. As long as the patient remains comfortable
ANS: B
When patients are able to sit up in a chair, make sure to limit the amount of time to
2 hours or less. The chair sitting time should be individualized. In the sitting
position, pressure on the ischial tuberosities is greater than in a supine position.
Utilize foam, gel, or an air cushion to distribute weight. Sitting for longer than 2
hours can increase the chance of ischemia.
2. The nurse is caring for a patient who is immobile and is at risk for skin
impairment. The plan of care includes turning the patient. Which is the best
method for repositioning the patient?
a. Place the patient in a 30-degree supine position.
b. Utilize a transfer device to lift the patient.
c. Elevate the head of the bed 45 degrees.
,d. Slide the patient into the new position.
ANS: B
When repositioning the patient, obtain assistance and utilize a transfer device to
lift rather than drag the patient. Sliding the patient into the new position will
increase friction. The patient should be placed in a 30- degree lateral position, not
a supine position. The head of the bed should be elevated less than 30 degrees to
prevent pressure ulcer development from shearing forces.
3. A nurse is assigned most of the patients with pressure ulcers. The nurse leaves
193
, the pressure ulcer open to air and does not apply a dressing. To which patient did
the nurse provide care?
a. A patient with a clean Stage I
b. A patient with a clean Stage II
c. A patient with a clean Stage III
d. A patient with a clean Stage IV
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14
days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be
utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium
alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with
foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An
unstageable wound covered with eschar should utilize a dressing of adherent film or
gauze with an ordered solution of enzymes.
4. The nurse is caring for a patient with a wound. The patient appears anxious
as the nurse is preparing to change the dressing. Which action should the nurse
take?
a. Turn on the television.
b. Explain the procedure.
c. Tell the patient “Close your eyes.”
d. Ask the family to leave the room.
ANS: B
Explaining the procedure educates the patient regarding the dressing change
and involves him in the care, thereby allowing the patient some control in
decreasing anxiety. Telling the patient to close the eyes and turning on the
television are distractions that do not usually decrease a patient’s anxiety. If the
family is a support system, asking support systems to leave the room can
actually increase a patient’s anxiety.
5. The nurse is cleansing a wound site. As the nurse administers the procedure,
which intervention should be included?
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