Exam 18: Pressure Ulcer Care

Pressure ulcers can occur in which area of the body? (Select all that apply.)

Pressure ulcers can occur: (Select all that apply.)

Factors that contribute to the development of pressure ulcers include: (Select all that apply.)

The client with a nasogastric (NG)tube in place may experience skin breakdown at the:

The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site does feel cooler than the areas immediately around the site.The nurse recognizes that this patient has developed:

A nurse assesses a stage II pressure ulcer as:

Aggressive prevention measures should be implemented for a client in the general population with a pressure ulcer risk on the Braden Scale of:

Any tension that stretches the skin during tuning or moving in bed is known as ______________.

The nurse is planning to care for her patient,who has a stage II pressure ulcer.Care should include which of the following? (Select all that apply.)

The nurse has been caring for a patient with a stage IV ulcer.The ulcer has been steadily improving and now almost is healed.The nurse,at this point,can classify the ulcer as a:

The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient,the nurse who is performing the assessment should pay particular attention to:

Anemia predisposes a client to pressure ulcers as a result of:

The nurse is caring for four patients on this shift.Who is at greatest risk for developing a pressure ulcer?

After teaching a home caregiver how to mange a pressure ulcer,the nurse realizes that further education is needed when the caregiver says:

The patient is admitted with an open pressure ulcer with necrotic tissue covering the base.The nurse would classify this ulcer as a:

A nurse classifies a pressure ulcer according to the color of the wound bed.A red wound has:

A _______________ is a localized injury to the skin and/or underlying tissue,usually over a bony prominence,as a result of pressure,or pressure in combination with shear and/or friction.

In a long-term care facility,reassessment of pressure ulcer risk is conducted:

When evaluating a client,a nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated.The nurse should:

The removal of devitalized tissue in a wound is known as ______________.