NURS Chapter 32 Flashcards
A pressure injury is
a. An open wound
b. Localized damage to the skin and underlying soft tissue
c. A bony prominence
d. Dead tissue
B
Pressure injuries are the result of
a. Unrelieved pressure
b. Moisture
c. Medical devices
d. Aging
A
Which of the following contribute to the development of pressure injuries?
a. Shear and friction
b. Slough and eschar
c. Bony prominences
d. CMS and TJC
A
A pressure injury can develop within
a. 2 to 6 hours
b. 6 to 10 hours
c. 10 to 14 hours
d. 14 to 18 hours
A
The following are risk factors for pressure injuries except
a. Urinary and fecal incontinence
b. Lowered mental awareness
c. Moisture
d. Balanced diet
D
Which is the most common site for a pressure injury?
a. Back of the head
b. Hip
c. Sacrum
d. Heel
C
In a light-skinned person, the first sign of a pressure injury is
a. A blister
b. A reddened area
c. Drainage
d. Gangrene
B
A person’s care plan includes the following. Which should you question?
a. Reposition the person every 2 hours
b. Scrub and rub the skin during bathing
c. Apply lotion to dry areas
d. Keep linens clean, dry, and wrinkle free
B
When positioning a person, you should position them
a. On an existing pressure injury
b. On a reddened area
c. On tubes or other medical devices
d. Using assist devices
D
What is the preferred position for preventing pressure injuries?
a. 30-degree lateral position
b. Semi-Fowler position
c. Prone position
d. Supine position
A
Besides heel and foot elevators, which are used to keep the heels and ankles off the bed?
a. Bed cradles
b. Pillows
c. Heel protectors
d. Sheepskin pads
B
Persons sitting in chairs should shift their positions every
a. 15minutes
b. 30minutes
c. Hour
d. 2 hours
A
A person is sitting in a chair. The feet do not touch the floor. What should you do?
a. Have the person slide forward until the feet touch the floor
b. Let the feet dangle
c. Stack pillows under the person’s feet
d. Position the feet on a footrest
D
Which are not used to treat pressure injuries?
a. Special beds
b. Gel or fluid-filled pads and cushions
c. Plastic drawsheets and waterproof pads
d. Heel and elbow protectors
C
The following are sources of moisture except
a. Urine and feces
b. Wound drainage
c. Perspiration
d. Barrier ointment
D
You see a reddened area on the person’s skin. What should you do?
a. Rub or massage the area
b. Apply a moisturizer
c. Apply a moisture barrier
d. Tell the nurse
D
The nurse tells you that the person’s pressure injury is colonized. This means that
a. The wound is infected
b. Bacteria are present
c. The person has osteomyelitis
d. The person has a wet-to-dry gauze dressing
B
Inflammation of the bone and bone marrow is
a. Osteoporosis
b. Osteomyelitis
c. Myositis
d. Myalgia
B
Which of the following is not a prevention measure for pressure injuries?
a. Reposition the person at least every 1 to 2 hours
b. Keep the heels and ankles off the bed
c. Massage bony areas
d. Change linens and garments as needed
C
Which is correct for preventing or treating pressure injuries?
a. Use hot water when bathing
b. Allow the person to stay in one position during the night
c. Keep the head of the bed raised as long as possible
d. Make sure shoes fit properly
D
