Skin Integrity And Pressure Injury Prevention - NCLEX Rn

Which heel intervention best prevents pressure injury for an immobile patient?

Float heels off the bed with a heel suspension device. Eliminates direct pressure on heels, a common site for injuries due to minimal subcutaneous padding.
Which ulcer type is caused by moisture and is not staged using pressure injury stages?

Moisture-associated skin damage (MASD). Results from prolonged exposure to urine, feces, or sweat, causing inflammation without pressure involvement.
Which two forces are the primary mechanical contributors to pressure injury development?

Pressure and shear. These forces cause tissue deformation and ischemia, leading to cellular damage and injury formation over bony prominences.
What does the term "unstageable pressure injury" mean?

Depth obscured by slough and/or eschar. Necrotic tissue prevents accurate depth assessment, requiring debridement before staging can occur.
Which wound tissue term describes black or brown nonviable tissue that can obscure depth?

Eschar. Forms a hard necrotic cover that hides underlying damage and must be debrided for assessment.
What is the correct description of a Stage 2 pressure injury?

Partial-thickness skin loss; exposed dermis. Involves loss of epidermis and partial dermis, presenting as a shallow ulcer without slough or bruising.
Which skin care action is most appropriate after cleansing incontinent skin to prevent breakdown?

Apply moisture barrier (zinc oxide or dimethicone). Creates a protective layer against irritants, maintaining skin integrity in moist environments.
Which head-of-bed position is recommended to reduce shear when not contraindicated?

Keep HOB at or below $30^\circ$ . Lowers sliding forces on sacral skin, balancing respiratory needs with shear prevention.
Which assessment tool is most commonly used on NCLEX to quantify pressure injury risk?

Braden Scale. Evaluates six subscales to predict risk, guiding preventive interventions in clinical practice.
What does "deep tissue pressure injury" typically present as?

Persistent deep red/maroon/purple discoloration. Reflects underlying soft tissue damage from intense pressure, potentially evolving to full-thickness injury.
Which nutritional issue is a major risk factor for impaired wound healing and pressure injury?

Protein-calorie malnutrition. Depletes essential nutrients for collagen synthesis and immune function, weakening skin resilience.
Which nursing intervention is the standard prevention for immobile patients to reduce pressure duration?

Scheduled repositioning/turning. Distributes pressure evenly and restores blood flow, preventing prolonged tissue compression.
What is the key clinical feature of a Stage 1 pressure injury?

Nonblanchable erythema of intact skin. Indicates early tissue damage where blood vessels are compromised, preventing the skin from lightening under pressure.
Identify the most appropriate dressing goal for a Stage 2 pressure injury with a moist wound bed.

Maintain a moist, protected environment. Promotes epithelial migration and granulation while preventing desiccation and infection.
What finding differentiates blanchable redness from a Stage 1 pressure injury?

Blanchable redness turns white with pressure. Blanching shows intact capillary perfusion, ruling out the ischemia characteristic of Stage 1 injuries.
Which Braden Scale category specifically evaluates exposure to moisture?

Moisture. Assesses skin exposure to incontinence or perspiration, which softens tissue and heightens vulnerability to friction.
Which finding most strongly suggests wound infection requiring provider notification?

Purulent drainage with increasing pain, redness, and warmth. Signals bacterial invasion and inflammation, necessitating prompt medical intervention to prevent sepsis.
What is the correct term for localized injury to skin and/or underlying tissue from pressure, or pressure with shear?

Pressure injury (pressure ulcer). This term accurately describes damage from prolonged pressure or shear, replacing outdated terms like bedsore for precision in clinical settings.
What is the correct description of a Stage 3 pressure injury?

Full-thickness skin loss; adipose visible. Damage extends through dermis to subcutaneous tissue, visible fat but no muscle or bone exposure.
What is the correct description of a Stage 4 pressure injury?

Full-thickness loss with exposed muscle/tendon/bone. Involves destruction through subcutaneous layers, exposing deeper structures and increasing infection risk.
Which repositioning strategy best reduces shear for a patient sliding down in bed?

Use lift sheet; avoid dragging; keep HOB low. Minimizes frictional forces on skin during movement, preventing tissue distortion and injury.
Which wound tissue term describes yellow or tan nonviable tissue that may be stringy or thick?

Slough. Represents devitalized tissue that impedes healing and requires removal for wound progression.
Which patient factor most directly increases pressure injury risk by reducing tissue perfusion?

Impaired circulation (e.g., hypotension/vascular disease). Compromises oxygen delivery to tissues, exacerbating ischemia under pressure and delaying healing.
Which support surface is preferred for a high-risk patient who cannot be repositioned adequately?

Pressure-redistribution mattress (e.g., low-air-loss). Reduces interface pressure over bony prominences, supporting tissue viability in immobile patients.
Which skin finding is most consistent with incontinence-associated dermatitis rather than a pressure injury?

Diffuse erythema with moisture-related maceration. Indicates moisture-induced irritation and softening, distinguishing it from pressure-related localized damage.

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