NSG 3023 CHAPTER 37 QUIZ | VERIFIED SOLUTION

NSG 3023 CHAPTER 37 QUIZ Chapter 37: Skin Integrity and Wound Care Potter: Essentials for Nursing Practice, 8th Edition MULTIPLE CHOICE 1. An elderly patient is admitted to the hospital for a bowel obstruction. The patient is immobile and the nurse notices that there is a reddened area on the right heel. When the nurse presses on the area it does not turn lighter in color. How should the nurse document the tissue condition? a. Reactive hyperemia b. Blanchable hyperemia c. Nonblanchable hyperemia d. Tissue ischemia The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed. The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation? a. Friction b. Shear c. Moisture d. Tunneling An elderly patient has been admitted to the hospital for pneumonia. Which factor could put this patient at risk for a pressure ulcer? a. A diet low in protein b. Braden Scale results of 22 c. Primary health care provider orders that read “activity as tolerated” d. Being repositioned every 2 hours A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage? a. Stage I b. Stage II c. Stage III d. Stage IV A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus. The admitting nurse notes that an area of redness on the right malleolus is nonblanchable. The nurse correctly identifies this pressure ulcer at what stage? a. Stage I b. Stage II c. Stage III d. Stage IV