BSN206 HALLMARK FINAL EXAM ALL 125 QUESTIONS AND CORRECT ANSWERS GRADED A+

BSN206 HALLMARK FINAL EXAM ALL 125 QUESTIONS AND CORRECT ANSWERS GRADED A+ Which of the following are common sites for the development of pressure injuries? (Select all that apply.) Sternum. Heels. Sacrum .Lateral malleoli. (ankle) bones Trochanters (hip region) .Ischial tuberosities. (sit bones) heels, sacrum, trochanters, ischial tuberosities, lateral malleoli Identify contributing factors to pressure injury formation. (Select all that apply.) Malnutrition. Middle age .Decreased sensory perception/mobility Anemia. Excessive sweating. Ethnic background. *mal nutrition (can impair skin integrity) *decrease sensory perception/mobility (inability to detect or relieve pressure *excessive sweating (moisture can contribute to skin breakdown) *Anemia (can reduce oxygen supply to tissue, affecting skin health) Three pressure-related forces contribute to the development of a pressure injury: intensity of pressure (how much pressure is applied), duration of pressure (how long the pressure is applied), and tissue tolerance (the ability of the tissue to redistribute the weight). Having decreased mobility or decreased ability to perceive the need to shift one's weight or change position places an individual at risk for pressure injury development. Three extrinsic factors, shear, friction, and moisture, make the tissues less tolerant of pressure. Other factors important in pressure injury development include poor nutrition, advanced age, medical conditions that support poor tissue perfusion (low blood pressure, smoking, elevated temperature, anemia), and psychosocial status, in particular stress-induced cortisol secretion. “ Identify prevention strategies for pressure injuries.] 1. Reposition patient at least every 4 hours; use a documented schedule. 2. When the patient is in the side-lying position in bed, use the 30-degree lateral position 3. Place patient on a pressure-reducing support surface. 4. Maintain the head of the bed at 45 degrees. 5. Massage reddened bony prominences. 6. Oral supplements should be instituted if the patient is found to be undernourished. 2, 3, 6 Patients should be repositioned every 2 hours to reduce the duration and intensity of pressure. The 30-degree lateral position avoids direct contact of the trochanter with the support surface. Placing the patient on a pressure-reducing support surface reduces the amount of pressure exerted against the tissues. The head of the bed should be maintained at 30 degrees. If the head is elevated more than this, it can increase the potential of the patient to slide toward the foot of the bed and incur a shear injury. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue, and therefore it should be avoided. A moisture barrier ointment protects reddened intact skin from incontinence. There is a strong relationship between poor nutrition and pressure injury development. Supplements may provide lacking nutrients “ The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? 1. She premedicates the patient for pain before beginning the dressing change. 2. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. 3. While wearing gloves, she rinses the injury with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze. 4. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. 5. She covers the gently packed wound with dry 4 × 4–inch gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene. 2. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. To avoid transfer of microorganisms, the caretaker should apply nonsterile gloves to remove the old dressing and discard the gloves and old dressing materials in a plastic bag. She should perform hand hygiene and apply new gloves before beginning to cleanse the wound. She should use the ordered solution, most generally normal saline, because soap can be very drying to tissues and may leave a residue. A family member calls the nurse to ask for advice regarding their mother who has developed a "bedsore" on her right heel. The family member describes the pressure injury as "a blister that has now popped and you can see redness." Based on this description, at what stage would the nurse classify this pressure injury? A. Stage 1. B. Stage 2 C. Stage 3. D. Stage 4. B. Stage 2 A stage 2 pressure injury can be described as an abrasion, a blister, or shallow crater with skin loss involving the epidermis and/or dermis. A stage 1 pressure injury appears as an area of color change (e.g., persistent redness) on intact skin. A stage 3 pressure injury presents clinically as a deep crater. A stage 4 pressure injury involves bone, muscle, or supporting structures. “ The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? 1. "To reduce the need for frequent dressing changes." 2. "To provide suction to remove and collect drainage from your wound to help it heal. "3. "To accurately determinine fluid loss and whether your fluids need to be increased." 4. "To prevent infection and crust formation at the wound site." 2. "To provide suction to remove and collect drainage from your wound to help it heal. The correct response would be "To provide constant suction to remove and collect drainage from your wound to help it heal." Although a Hemovac drain will collect drainage, the Hemovac drain is used to provide constant low-pressure suction to remove and collect drainage from the wound bed to allow the tissues to come together to heal. Measuring the amount of drainage is used to determine when the drain may be removed. A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? 1. "I should empty the drain when it is one-half to two-thirds full." 2."I should keep a record of how much drainage I empty." 3. "If drainage suddenly stops, it means the drain is ready to be removed.