Skin Integrity And Pressure Injury Prevention - NCLEX Pn

What is the key difference between shear and friction in skin breakdown?

Shear: deep tissue stretch; friction: epidermal rubbing. Shear distorts underlying tissues through parallel forces, while friction abrades the superficial skin layers against external surfaces.
Which support surface is most appropriate for a patient at high risk for pressure injuries?

Pressure-redistributing mattress or mattress overlay. Specialized surfaces evenly distribute weight, reducing peak pressures on vulnerable bony prominences to prevent injury.
What is the priority nursing action to prevent skin breakdown in an incontinent patient?

Cleanse promptly and apply a moisture barrier protectant. Immediate cleansing removes irritants, while barriers shield skin from moisture, preventing maceration and breakdown.
Which finding best defines a Stage 1 pressure injury?

Nonblanchable erythema of intact skin. Indicates initial tissue damage where pressure impairs perfusion, preventing the reddened area from paling under light fingertip pressure.
Which finding best defines a Stage 3 pressure injury?

Full-thickness skin loss; adipose visible; no bone/tendon. Involves tissue destruction through the dermis into subcutaneous layers, exposing fat but not reaching muscle, tendon, or bone.
Which finding best defines a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis. Represents superficial ulceration involving loss of epidermis and partial dermis, often appearing as a shallow crater or ruptured blister.
Which action best reduces shear when elevating the head of bed for a high-risk patient?

Keep head of bed at or below $30^\circ$ when possible. Lower elevations minimize sliding forces that create shear stress on sacral and coccygeal tissues during bed elevation.
Which repositioning schedule is commonly used for a patient seated in a chair or wheelchair?

Pressure relief at least every 1 hour while seated. Seated postures concentrate higher pressure on smaller areas like ischia, necessitating more frequent relief to prevent injury.
Which skin condition most increases risk of pressure injury due to moisture-associated damage?

Incontinence-associated dermatitis from urine or stool. Prolonged exposure to irritants macerates skin, reducing its barrier function and heightening vulnerability to pressure damage.
Which action is correct when assessing possible Stage 1 injury in darkly pigmented skin?

Assess temperature, firmness, and pain rather than blanching. Pigmentation masks color changes, so tactile and sensory cues better detect early pressure damage in darker skin tones.
Which option is best practice regarding "donut" or ring cushions for pressure injury prevention?

Avoid donut cushions; they increase localized pressure. Ring designs concentrate pressure peripherally, potentially causing ischemia in the central area intended for protection.
Which patient finding is the strongest risk factor for pressure injury development?

Immobility or significantly limited mobility. Prevents independent pressure relief, allowing continuous compression on bony prominences and increasing ischemia risk.
What does the term "unstageable pressure injury" mean?

Depth obscured by slough or eschar. Necrotic tissue obscures the wound base, preventing determination of the true extent of tissue loss until debridement occurs.
Which tissue type is described by yellow or tan, stringy material in a wound bed?

Slough. Represents devitalized, adherent tissue that must be removed to promote healing and assess the underlying wound bed.
Which finding best defines a Stage 4 pressure injury?

Full-thickness loss with exposed bone, tendon, or muscle. Signifies extensive destruction penetrating to musculoskeletal structures, heightening risks like infection and delayed healing.
What is the primary mechanism that causes a pressure injury to develop over a bony prominence?

Sustained pressure causing ischemia and tissue necrosis. Prolonged compression over bony areas restricts blood flow, leading to oxygen deprivation and subsequent cell death in vulnerable tissues.
Which nutritional factor is most directly associated with impaired wound healing and skin breakdown?

Protein-calorie malnutrition. Deficiencies impair collagen synthesis, immune response, and tissue repair, delaying healing and increasing breakdown risk.
What does "deep tissue pressure injury" most typically look like on assessment?

Persistent nonblanchable deep red/maroon/purple discoloration. Reflects underlying soft tissue damage from intense pressure or shear, often progressing to reveal full-thickness injury.
Which documentation element is essential when charting a pressure injury at each assessment?

Stage, location, size, drainage, wound bed, and periwound skin. Detailed recording tracks wound progression, informs care planning, and ensures continuity among healthcare providers.
Which assessment finding indicates intact capillary refill and rules out Stage 1 injury on light skin?

Blanching erythema (redness turns white with pressure). Demonstrates intact perfusion as pressure displaces blood temporarily, distinguishing reactive hyperemia from true injury.
Which intervention is most appropriate to offload pressure from the heels in a bedbound patient?

Float heels off the bed with pillows or a heel suspension device. Suspends heels to eliminate direct contact with surfaces, reducing pressure and promoting blood flow to prevent ulcers.
Which option best describes granulation tissue in a healing wound?

Moist, beefy red or pink tissue. Signifies active healing as new vascular tissue fills the wound defect with collagen and capillaries.
Identify the correct technique to move a patient up in bed to prevent friction and shear.

Use a drawsheet or lift device; do not drag the patient. Lifting eliminates dragging-induced friction and shear, protecting skin integrity during patient repositioning in bed.
Which tissue type is described by black or brown, leathery necrotic tissue in a wound?

Eschar. Forms a dry, adherent crust of necrotic tissue that protects but can harbor infection if not appropriately managed.
Which repositioning schedule is the standard preventive intervention for a bedbound patient?

Reposition at least every 2 hours. Frequent position changes alleviate sustained pressure, restoring circulation and minimizing tissue ischemia over time.

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