Clinical Nursing Skills Updated 2025
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When assessing a client's skin, the nurse observes an area of deep purple
discoloration on the client's heel. The skin in that area is intact. How will the nurse
document this finding?
a. stage 2 pressure injury
b. unstageable, skin intact
c. stage 1 pressure injury
d. deep tissue injury - ANSWER ✓ d. deep tissue injury
Place in order, from first to last, these actions the nurse will perform when
providing wound care to a client with a pressure injury. Use all options
1. remove old dressing
2. assess the wound bed
3. put on clean gloves
4. time and date the dressing
5. open dressing materials
6. irrigate the wound bed - ANSWER ✓ Put on clean gloves.
Remove old dressing.
Assess the wound bed.
Open dressing materials.
Irrigate the wound bed.
Time and date the dressing.
Which client is a greatest risk of developing a pressure injury?
, a. a 84 yr old client diagnosed w a uti who frequently gets out of bed without
calling for assistance
b. 47 yr old client w severe alcoholism and tbi resulting in unconsciousness
c. 17 yr old client postoperative for fracture of the upper extremity
d. 25 yr old client on bed rest for 24 hours following a procedure - ANSWER ✓ b.
47 yr old client w severe alcoholism and tbi resulting in unconsciousness
The nurse is caring for a client with a pressure injury and is applying a saline-
moistened dressing to the wound. What does the nurse understand to be the
primary rationale for using a saline-moistened dressing?
a. to prevent the dressing from sticking to the wound
b. to fill the wound w saline to dissolve wound secretions
c. to promote moist wound healing and protect the wound from contamination and
trauma
d. to soften the dressing to prevent trauma to the wound bed - ANSWER ✓ c. to
promote moist wound healing and protect the wound from contamination and
trauma
The nurse is teaching a client's caregiver about ways to help prevent skin
breakdown. What would the nurse teach as an important intervention to prevent
pressure injury development?
a. pull the client up in the bed very gently
b. gently massage any reddened areas for several mins
c. keep the head of the bed elevated 35 degrees
d. turn and reposition the client every 2 hrs - ANSWER ✓ d. turn and reposition
the client every 2 hrs
Which client would be at greatest risk for developing a pressure injury?
a. older adult client who has COPD
b. adult client who is comatose
c. adolescent client w a cast on the left leg
d. client who is delirious after taking pain meds - ANSWER ✓ b. adult client who
is comatose
Which assessment findings will the nurse use to determine the stage of a client's
pressure injury? Select all that apply.