- A 76-year-old client is hospitalized with sepsis and is receiving vasopressors; the client is minimally responsive and cannot reposition independently. Skin is cool with delayed capillary refill; heels are intact but reddened, and the sacral area is intact with mild erythema. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Place pillows to float the heels off the bed and use a pressure-redistribution mattress while minimizing shear during repositioning
This question tests application of pressure injury prevention in hemodynamically unstable patients. The key aspect is balancing pressure injury prevention with cardiovascular stability in critically ill patients. Floating heels and using pressure-redistribution surfaces while minimizing shear (A) is the best intervention because it provides essential pressure relief without compromising hemodynamic stability through careful, minimal-shear repositioning techniques. Talcum powder (B) can cake with moisture and cause skin irritation; keeping HOB at 45 degrees continuously (C) increases sacral pressure and shear; and delaying all repositioning (D) guarantees pressure injury development. The principle is that even unstable patients need pressure relief, but techniques must be modified to minimize hemodynamic impact. A transferable strategy is to use passive positioning aids (heel floatation, pressure-redistribution surfaces) and gentle, coordinated turning techniques for patients too unstable for frequent full repositioning.
- An 84-year-old resident in a long-term care facility is bedbound with advanced dementia and contractures. The resident has a stage 2 pressure injury on the right heel with a shallow, pink wound bed and scant serous drainage; surrounding skin is intact. The resident is incontinent of urine and has poor oral intake. What is the PRIORITY action for maintaining skin integrity and promoting healing?
Answer: Offload the heel by floating it with pillows or a heel-protection device and keep pressure off the area at all times
For a stage 2 heel pressure injury, the priority is complete pressure relief. Offloading the heel — floating it with pillows or a heel-protection device and keeping pressure off at all times — is correct because the heel has minimal subcutaneous tissue and needs total offloading to heal, not redistribution of pressure. Cleansing with full-strength povidone-iodine is harmful: it is cytotoxic and delays wound healing; the appropriate care is gentle cleansing with saline or a wound cleanser. Asking the resident to rate pain is a reasonable comfort measure, but pain assessment does not address the ongoing pressure causing tissue damage, so it cannot be the priority. A donut-shaped cushion appears to relieve pressure but actually creates a ring of pressure around its rim, which can compromise the surrounding intact skin and worsen the ulcer. The key principle is that any heel at risk of or with a pressure injury must be completely free-floating off the bed surface.
- A 60-year-old post-surgical client is unable to reposition independently and has a Braden Scale score of 9. The nurse notes the client is lying on wrinkled linens and has crumbs in the bed; skin is intact. What is the PRIORITY action for maintaining skin integrity?
Answer: Remove wrinkles and debris from the bed and reposition the client using a lift sheet to reduce friction and shear
The priority is to remove the direct mechanical risks: wrinkled linens and crumbs are sources of friction and pressure in a client who cannot reposition and has a Braden score of 9. Removing them and using a lift sheet reduces skin trauma during movement. Applying scented lotion focuses on comfort and dry skin, but it does not address the immediate bed environment and the risk of friction and shear; a provider order to change linens or clarify repositioning is unnecessary because changing linens, removing debris, and repositioning are nursing responsibilities. Getting a dietary history is not the priority before addressing the actual wrinkled linens; nutrition is important but this is a later concern while the client remains on an unsafe surface. Therefore, the action that both cleans the environment and reduces friction with a lift sheet is the direct best answer.
- A 63-year-old client is postoperative day 2 after spinal surgery and must maintain spinal precautions; the client is mostly supine and needs assistance to turn. The client is diaphoretic and has a urinary catheter; nutrition intake is poor. On assessment, the nurse notes a new 2 cm intact, fluid-filled blister on the sacrum with surrounding nonblanchable erythema. Which assessment finding requires IMMEDIATE intervention for pressure injury risk?
Answer: New intact, fluid-filled blister on the sacrum with surrounding nonblanchable erythema
This question tests application of pressure injury prevention by recognizing stage 2 pressure injury development. The key aspect is identifying that an intact fluid-filled blister with surrounding nonblanchable erythema represents a stage 2 pressure injury requiring immediate intervention. The new blister on the sacrum (B) requires immediate intervention because it indicates partial-thickness tissue loss has occurred, and without prompt pressure relief and proper wound care, it will rapidly progress to deeper tissue damage. Poor appetite (A) needs addressing but isn't immediately urgent; diaphoresis (C) requires comfort measures; and the catheter (D) is functioning normally. The principle is that intact blisters over pressure areas represent stage 2 injuries that can quickly deteriorate if pressure continues. A transferable strategy is to treat any blister over a bony prominence as a medical urgency requiring immediate pressure relief and appropriate wound care to prevent progression.
- A 70-year-old client is hospitalized with a hip fracture and is on bedrest awaiting surgery. The client is thin (body mass index 18), has urinary incontinence, and needs assistance to turn. Skin assessment shows intact skin with nonblanchable redness on the left trochanter; vital signs: T 36.6°C (97.9°F), HR 84, RR 16, BP 128/72. What is the PRIORITY action for maintaining skin integrity?
Answer: Reposition the client to offload the left trochanter and initiate a turning schedule with pressure-redistribution support
This question tests application of pressure injury prevention when discovering stage 1 pressure injury. The key aspect is immediate pressure relief when nonblanchable erythema is identified, indicating tissue damage has begun. Repositioning to offload the trochanter and initiating a turning schedule with pressure redistribution (C) is the priority because immediate and consistent pressure relief is essential to prevent progression from stage 1 to deeper tissue damage. Simply documenting and waiting (A) allows continued pressure and tissue damage; transparent film alone (B) without pressure relief won't prevent progression; and antiseptic with vigorous rubbing (D) causes additional tissue trauma. The principle is that nonblanchable erythema represents actual tissue damage requiring immediate and sustained pressure relief. A transferable strategy is to implement immediate offloading and structured repositioning whenever nonblanchable erythema is discovered, treating it as an urgent situation.
- A 74-year-old hospitalized client is immobile due to severe pneumonia and is receiving intravenous fluids. The nurse notes blanchable redness on both heels; the client reports no heel pain. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Float the heels off the bed using pillows under the calves and ensure the heels are not in contact with the mattress
This question tests the application of pressure injury prevention in an immobile client with early heel redness. The key aspect is offloading pressure from heels to halt progression of breakdown. Floating the heels off the bed using pillows under the calves is the best intervention as it eliminates direct pressure on the heels. Warm compresses can cause burns; donut protectors concentrate pressure; limiting repositioning increases risk. A principle of skin care is to use offloading devices for bony prominences. Regular assessments detect changes early. A transferable strategy is to incorporate heel protection into care plans for bedbound clients to prevent common pressure injuries.
- A 73-year-old hospitalized client with chronic obstructive pulmonary disease is weak and requires assistance to sit in a chair. The nurse notes the client has been sitting for 4 hours; skin over the ischial tuberosities is red and nonblanchable. Which assessment finding requires IMMEDIATE intervention for pressure injury risk?
Answer: Nonblanchable redness over the ischial tuberosities after prolonged sitting
This question tests the application of pressure injury prevention by recognizing acute risks from prolonged positioning. The key aspect is identifying nonblanchable redness as an indicator of stage 1 pressure injury needing immediate relief. Nonblanchable redness over the ischial tuberosities requires immediate intervention because it signifies tissue damage from extended sitting. Respiratory changes, thirst, and capillary refill are less directly related to pressure risk. A principle of injury prevention is to limit sitting time and encourage shifts. Skin assessments after positioning detect issues. A transferable strategy is to monitor positioning duration in weak clients to intervene promptly.
- A 70-year-old long-term care resident with a stage 2 sacral pressure injury reports pain during turning. The wound bed is pink and moist with scant serous drainage; surrounding skin is intact. Which intervention should the nurse implement to promote healing and prevent deterioration?
Answer: Premedicate for pain as appropriate and continue a consistent repositioning schedule with pressure redistribution
This question tests the application of pressure injury prevention and wound healing in a resident with an existing pressure injury and pain during care. The key aspect is balancing pain management with essential repositioning to avoid further tissue damage. Premedicating for pain and continuing consistent repositioning with pressure redistribution is the best intervention as it ensures mobility while controlling discomfort. Leaving the wound open to air risks drying and infection; massaging can cause trauma; povidone-iodine is cytotoxic to healing tissue. A principle of injury prevention is to maintain a moist wound environment for optimal healing. Pain assessment and management support adherence to care plans. A transferable strategy is to integrate multidisciplinary approaches, including pain control, to promote overall skin integrity.
- An 83-year-old hospitalized client with advanced dementia is nonambulatory and is fed by staff. The client is incontinent of urine and stool; skin is excoriated in the perineal area, and the sacrum is intact with blanchable redness. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Apply a moisture barrier ointment after each incontinence episode and implement a scheduled toileting and cleansing plan
This question tests the application of pressure injury prevention in a client with dementia, immobility, and incontinence leading to skin excoriation. The key aspect is protecting perineal skin from moisture-associated damage while addressing early sacral redness. Applying a moisture barrier ointment after each incontinence episode and implementing scheduled toileting and cleansing is the best intervention as it minimizes skin exposure to irritants and promotes dryness. Hot water and scrubbing can further damage skin; donut cushions are contraindicated as they can impair circulation; waiting for a consult delays care. A principle of skin care is gentle cleansing with pH-balanced products after incontinence. Consistent interventions prevent progression from redness to ulceration. A transferable strategy is to develop individualized incontinence management plans to safeguard vulnerable skin in dependent clients.
- A 69-year-old hospitalized client with Parkinson disease has limited mobility and requires assistance for toileting. The nurse notes the client's skin is dry and fragile; there are no open areas. Which order related to skin care should the nurse QUESTION?
Answer: Use hot water and antibacterial soap for daily baths to reduce infection risk.
The order to question is the one that recommends hot water and antibacterial soap for daily baths. Hot water draws moisture out of the skin, and antibacterial soap is unnecessarily harsh for dry, fragile skin, especially when no open areas are present. The recommended alternative is lukewarm water and a mild cleanser. The pH-balanced moisturizer is appropriate because moisturizing after bathing supports the skin barrier in a client with dry skin. A lift sheet is also appropriate because it reduces friction and shear during assisted repositioning. Likewise, a regular turning schedule with documented skin care is standard pressure injury prevention. Therefore, the nurse should question the only order that risks worsening skin dryness and fragility.
- A 90-year-old long-term care resident with heart failure is chairbound and requires total assistance for repositioning. The resident has a stage 2 pressure injury on the coccyx with a pink, moist wound bed and moderate serous drainage; periwound skin is fragile. The resident is incontinent and has albumin 2.8 g/dL; vital signs are stable. Which intervention should the nurse implement to prevent pressure injuries and support healing?
Answer: Cleanse the wound with normal saline and apply a moisture-retentive dressing while protecting periwound skin with a barrier product
The correct intervention cleanses with normal saline, applies a moisture-retentive dressing, and protects periwound skin with a barrier product, maintaining the moist environment needed for stage 2 healing while preventing maceration of fragile skin. Leaving the wound open to air to dry the bed causes desiccation and delays healing. Prophylactic systemic antibiotics, even when a wound is draining and the resident is incontinent, are not indicated for uninfected injuries and risk promoting resistance. Massaging the periwound area, even with an emollient, can damage fragile capillaries and worsen breakdown. The choice that preserves moisture and shields periwound tissue is the only one that directly supports healing and prevention.
- An 81-year-old hospitalized client with limited mobility has a Braden Scale score of 12 and is at high risk for pressure injury. The nurse receives the following orders. The nurse should QUESTION which order related to skin care?
Answer: Massage reddened bony prominences every shift to prevent skin breakdown
This question tests the application of pressure injury prevention strategies in a high-risk client. The key aspect involves identifying inappropriate interventions that could compromise skin integrity in a client with a low Braden Scale score indicating high risk. The nurse should question the order to massage reddened bony prominences because this can cause further tissue damage and is contraindicated in pressure injury prevention guidelines. Option A is appropriate as repositioning every 2 hours and using pillows reduce pressure on bony areas; option B is correct for protecting skin from moisture; and option D minimizes friction and shear, which are risk factors for skin breakdown. A fundamental principle of skin care is to avoid actions that increase trauma to vulnerable tissues, such as massaging areas of redness. Effective injury prevention includes regular assessment and evidence-based interventions tailored to individual risk factors. A transferable strategy is to routinely use validated tools like the Braden Scale to guide and prioritize preventive measures in immobile clients.
- A 72-year-old client is 1 day post–total hip arthroplasty and is reluctant to move due to pain; mobility is limited to dangling at the bedside with assistance. The client has a Braden Scale score of 13, is diaphoretic, and has moisture-associated redness in the gluteal cleft; vital signs are stable. Which assessment finding requires IMMEDIATE intervention for pressure injury risk?
Answer: Diaphoresis with moist skin in dependent areas
This question tests the application of pressure injury prevention by identifying immediate risks in a postoperative client with limited mobility. The key aspect is recognizing moisture as a significant risk factor for skin breakdown, especially in dependent areas like the gluteal cleft. Diaphoresis with moist skin in dependent areas requires immediate intervention because excess moisture can macerate skin and increase friction. Pain with movement, stable vital signs, and poor sleep are relevant but do not pose the same acute risk for pressure injury as moisture does. A principle of injury prevention is to keep skin clean and dry while managing incontinence or perspiration promptly. Regular skin assessments help identify early changes like redness. A transferable strategy is to integrate moisture management into care plans for all clients with mobility restrictions to prevent complications.
- A 66-year-old client is postoperative day 1 after open abdominal surgery and is reluctant to turn due to pain. The client requires assistance to reposition and is receiving opioid analgesia; Braden Scale score is 12 (high risk). Current assessment shows intact skin with blanchable erythema over both heels and dry, flaky skin on the lower legs. Which assessment finding requires IMMEDIATE intervention for pressure injury risk?
Answer: Blanchable erythema over both heels
This question tests application of pressure injury prevention by identifying early warning signs requiring immediate intervention. The key aspect is recognizing that blanchable erythema over bony prominences indicates tissue stress and impending injury risk. Blanchable erythema over both heels (B) requires immediate intervention because it signals reactive hyperemia and tissue stress that can quickly progress to nonblanchable erythema if pressure is not relieved. Dry skin (A) needs moisturizing but is not urgent; pain with movement (C) needs management but is expected postoperatively; and vital signs (D) are within normal limits. The principle is that blanchable erythema is a critical early warning sign that tissue damage is beginning, and immediate pressure relief can prevent progression. A transferable strategy is to prioritize interventions for any blanchable erythema over bony prominences, as this represents the last opportunity to prevent irreversible tissue damage.
- A 62-year-old home care client with rheumatoid arthritis has limited hand strength and cannot apply lotion well. The client has intact skin but frequent scratching due to dryness; mobility is limited and the client naps in bed during the day. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Arrange adaptive equipment or caregiver support to apply moisturizer and support regular repositioning and skin checks
The priority is to keep dry, intact skin hydrated and to prevent unrelieved pressure. The correct intervention does both: arranging adaptive equipment or caregiver support compensates for the client's limited hand strength so moisturizer can be applied, while regular repositioning and skin checks reduce pressure risk. Rubbing alcohol after bathing is not helpful; it dries and irritates the skin and does nothing to reduce pressure. Encouraging the client to stay in one position, even to ease joint pain, increases prolonged pressure and directly raises the risk of a pressure injury. Talcum powder is not a moisturizer; it can cake or irritate, and applying it daily does not redistribute pressure or prompt skin inspection. The best answer directly addresses both the need for skin moisture and the need for movement and surveillance.
- A 78-year-old hospitalized client is on bed rest after an ischemic stroke with right-sided weakness and requires two-person assistance to reposition. History includes type 2 diabetes and urinary incontinence; Braden Scale score is 12. Skin is warm and intact but there is nonblanchable erythema over the sacrum. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Reposition the client at least every 2 hours using a draw sheet and offload the sacrum with pillows or wedges
The best response is to reposition the client at least every 2 hours using a draw sheet and offload the sacrum with pillows or wedges. Nonblanchable erythema over a bony prominence is an early pressure injury signal; the priority is to relieve sustained pressure and shear. Massaging the reddened sacral area is harmful because it can damage fragile capillaries and worsen ischemia. Documenting the erythema and reassessing at the end of the shift is passive monitoring; the nurse should act immediately, not wait. Requesting a provider order before applying a moisture barrier is unnecessary because moisture barriers are within nursing scope, and this action does not offload the sacrum. Moisture management matters, but pressure offloading takes priority for this client with immobility, diabetes, incontinence, and a Braden score of 12.
- A 59-year-old home care client with multiple sclerosis ambulates short distances with a walker and spends most of the day in a recliner. The client reports occasional urinary leakage and has dry, flaky skin on the legs; no open areas are present. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Teach the client to shift weight at least every 15 minutes while sitting and to change position at least every 2 hours when resting.
The correct intervention is to teach the client to shift weight every 15 minutes while sitting and to change position every 2 hours when resting. This redistributes pressure and prevents the prolonged ischemia that leads to pressure injuries. Limiting fluid intake in the evening addresses urine leakage, not pressure, and can lead to poor hydration, which makes skin more vulnerable. Talcum powder and absorbent pads also address moisture, not pressure; powder can cake and irritate the perineum and pads do not protect one side from pressure. A donut-shaped cushion is not recommended because the ring increases pressure on the sacral area rather than removing it. For this client, scheduled weight shifting and repositioning are the safest, most reliable preventive measures.
- A 71-year-old hospitalized client is receiving enteral tube feedings and is on bed rest after a gastrointestinal bleed. The client has edema and is incontinent of urine; Braden Scale score is 10. Skin is intact but moist in the groin folds. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Keep skin clean and dry, use moisture-wicking textiles as available, and apply a moisture barrier to areas exposed to urine.
The client is at high risk for pressure injury because of immobility, edema, and urinary incontinence. The best prevention in this moist, intact skin situation is active moisture management: keeping the skin clean and dry, using moisture-wicking textiles when available, and applying a moisture barrier to skin exposed to urine. These actions directly reduce maceration in the groin folds and protect intact skin from breakdown.
Waiting for a provider order to start turning and keeping the client supine delays pressure relief; turning is a standard nursing intervention and should be implemented promptly. Cornstarch is not a substitute for a moisture barrier. It can cake in skin folds, trap moisture, and promote fungal irritation, especially when urine exposure is ongoing. Reducing the frequency of perineal care also leaves urine on fragile skin, because the skin's natural oil cannot replace the deeper cleansing and barrier protection needed after incontinence. The correct response is the only one that actively removes and blocks moisture rather than delaying care or adding an ineffective product.
- A 76-year-old home care client with a recent hospitalization for heart failure is weak and spends most of the day in bed. The client has intact skin, but the caregiver reports the client is "too tired" to turn; the client has poor appetite and drinks little. Which intervention should the nurse implement to prevent pressure injuries?
Answer: Teach the caregiver a written turning schedule, demonstrate safe repositioning with pillows for offloading, and encourage adequate nutrition and hydration within prescribed limits
This question tests the application of pressure injury prevention through caregiver education in a weak home client. The key aspect is addressing fatigue and nutrition to support mobility and tissue health. Teaching a turning schedule, safe repositioning, and nutrition encouragement is the best intervention as it empowers the caregiver to prevent breakdown. One position increases risk; vigorous rubbing damages skin; donut cushions are contraindicated. A principle of injury prevention is balanced nutrition for resilience. Hydration supports healing. A transferable strategy is to provide written resources for caregivers to ensure consistent prevention at home.
- An 82-year-old long-term care resident with chronic kidney disease and poor oral intake has a stage 2 pressure injury on the right trochanter. The resident eats about 25% of meals; weight has decreased by 3 kg over 1 month; vital signs are stable. Which intervention should the nurse implement to promote healing and prevent further skin breakdown?
Answer: Collaborate with the dietitian to increase protein and calorie intake within renal diet parameters and offer oral nutrition supplements
This question tests the application of pressure injury prevention through nutritional support in a resident with chronic illness and a wound. The key aspect is enhancing protein and calorie intake to promote wound healing and prevent further breakdown. Collaborating with the dietitian to increase intake within renal parameters and offering supplements is the best intervention as nutrition is crucial for tissue repair. Restricting protein hinders healing; delaying until infection ignores current needs; orders are not required for encouragement. A principle of injury prevention is optimizing nutrition for collagen synthesis. Monitoring weight guides interventions. A transferable strategy is to assess nutritional status regularly in at-risk clients to support skin integrity.
