Pressure ulcers develop from prolonged pressure, especially over bony areas, leading to tissue ischemia and necrosis. Contributing factors include immobility, poor nutrition, moisture, friction, and shear. Certain conditions-like fever or long surgeries-increase vulnerability by reducing perfusion or increasing metabolic demands. Preventive measures include frequent repositioning, maintaining adequate nutrition, and managing moisture.

Rationale for correct answers:

1. Low-protein diet: Protein is essential for tissue repair and skin integrity. Malnutrition and a low-protein diet cause decreased collagen formation and slower wound healing, making skin more prone to breakdown and ulceration.

3. Lengthy surgical procedures: Clients undergoing long surgeries are immobile for extended periods, which leads to sustained pressure on bony prominences and impaired tissue perfusion, a major risk factor for pressure ulcer development.

4. Fever: Fever increases metabolic demands and causes sweating, leading to moisture and skin maceration. It also increases tissue oxygen consumption, which can predispose skin to breakdown if perfusion is compromised.

Rationale for incorrect answers:

2. Insomnia: While lack of sleep may affect general health, it does not directly cause pressure ulcers. Pressure ulcers are caused primarily by prolonged pressure, friction, shear, and poor nutrition-not by sleep disturbances.

5. Sleeping on a waterbed: A waterbed actually helps distribute pressure more evenly, reducing the risk of pressure ulcers. It can be beneficial for clients at risk, as it minimizes localized pressure points.

Take home points

• Key risk factors for pressure ulcers include immobility, poor nutrition, and increased metabolic demands such as those from fever.
• Preventive strategies-turning schedules, good nutrition, and moisture control-are essential to preserve skin integrity.

Understanding the characteristics of wound exudate (serous, sanguineous, serosanguineous, purulent) helps nurses evaluate wound status, identify infection, and determine appropriate interventions (culture, antibiotic therapy, wound cleansing, dressing selection). Purulent drainage is a hallmark of infection and should prompt further assessment, culture, and communication with the provider.

Rationale for correct answer:

4. Purulent: Purulent drainage is thick, often discolored (yellow, green), and frequently malodorous - it usually indicates the presence of pus and infection (neutrophils, bacteria, necrotic debris).

Rationale for incorrect answers:

1. Serous: Serous drainage is thin, clear to pale yellow - like plasma - and is not odorous or green.

2. Sanguineous: Sanguineous drainage is fresh blood - bright red - indicating active bleeding; not thick, odorous, or green.

3. Serosanguineous: Serosanguineous is a thin, pinkish mixture of serous fluid and a small amount of blood. It’s not typically thick, malodorous, or green.

Take home points

• Purulent, thick, green, or foul-smelling drainage - suspicion of infection - requires wound culture, appropriate wound care, and notification to obtain antibiotic therapy as indicated.
• Describing drainage accurately (color, consistency, odor, and amount) is essential for tracking wound progress and guiding treatment.

The Braden Scale is a standardized tool used by nurses to assess a client's risk of developing pressure ulcers (bedsores). It evaluates six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6 to 23, with lower scores indicating greater risk. Based on the total score, nursing interventions are implemented to prevent skin breakdown - ranging from simple measures like turning schedules to advanced support surfaces for higher-risk clients.

Rationale for correct answer:

2. Implement a turning schedule; the client is at increased risk of skin breakdown: A score of 15–18 indicates mild risk, so preventive interventions are required. The nurse should implement frequent repositioning (every 2 hours), encourage mobility, and keep the skin clean and dry to reduce pressure and moisture-related damage.

Rationale for incorrect answers:

1. Assess the client again in 24 hours; the score is within normal limits: A Braden Scale score of 17 indicates mild risk for pressure ulcer development, not normal limits. Normal (no risk) is a score of 19–23. Therefore, waiting 24 hours without intervention could lead to preventable skin breakdown.

3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown: A Braden score of 17 does not reflect moderate risk (which is 13–14). Applying a transparent film may be appropriate for existing wounds or higher-risk clients, but at this score, repositioning and skin inspection are more appropriate interventions.

4. Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown: A very high risk category applies to scores ≤9. Specialized beds are used for clients at very high or high risk (≤12). This intervention would be unnecessary and not cost-effective for a client scoring 17.

Take home points

• A Braden score of 17 - mild risk, requiring preventive nursing actions such as repositioning, skin inspection, and moisture control.
• Early intervention prevents pressure ulcers- waiting for skin breakdown before acting increases morbidity, care costs, and recovery time.

Pressure injury staging classifies the depth and severity of tissue damage: Stage I (intact skin, non-blanchable redness), Stage II (partial-thickness skin loss - abrasions, blisters, shallow open ulcers), Stage III (full-thickness skin loss with subcutaneous tissue involvement), and Stage IV (full-thickness loss with exposed bone, tendon, or muscle). Correct staging guides treatment choices, documentation, and communication among caregivers.

Rationale for correct answer:

2. Stage II describes partial-thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed, or as an intact or open/ruptured serum-filled blister. A reddened area that has blistered fits the Stage II definition.

Rationale for incorrect answers:

1. Stage I is non-blanchable erythema of intact skin (redness that doesn’t blanche) but the skin is still intact and there is no blistering or partial-thickness loss.

3. Stage III indicates full-thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to (but not through) underlying fascia; you would see deeper tissue loss, possibly fat, not just a superficial blister.

4. Stage IV is full-thickness tissue loss with exposed bone, tendon, or muscle and often extensive necrosis or damage - far deeper and more severe than a blistered reddened area.

Take home points:

• A blistered reddened area- Stage II (partial-thickness injury); intact non-blanching redness alone- Stage I.
• Accurate staging matters - it directs wound care, prevention strategies, and legal/quality documentation.

Wounds heal by primary, secondary, or tertiary intention depending on how the wound edges close. Primary intention involves direct closure (e.g., surgical wounds), while secondary and tertiary involve open wounds or delayed closure due to infection or tissue loss.

Rationale for correct answer:

4. Surgical incision: Surgical wounds are clean and closed with sutures or staples, allowing the wound edges to approximate directly. Healing occurs quickly with minimal scar formation.

Rationale for incorrect answers:

1. Second-degree burn: Burns heal by secondary intention, involving tissue regeneration and scar formation due to partial-thickness loss.

2. Pressure ulcer: Heals by secondary or tertiary intention, depending on depth and infection status, since wound edges cannot be easily approximated.

3. Traumatic injury: Usually heals by secondary or tertiary intention, depending on tissue loss and contamination.

Take home points:

• Primary intention healing occurs in clean, closed wounds like surgical incisions.
• Secondary and tertiary intention apply to open or infected wounds requiring granulation and longer healing times.

A wound culture is performed to identify the microorganisms causing infection and to guide antibiotic therapy. Proper technique is critical for accuracy. The nurse should cleanse the wound with normal saline first, avoiding contamination from surface debris or exudate, and collect the specimen from viable tissue using a sterile swab or aspirate. Incorrect technique may lead to false results and inappropriate treatment.

Rationale for correct answer:

1. Cleansing the wound prior to obtaining the specimen: The wound should always be cleansed with normal saline before collecting a culture to remove surface contaminants such as dead tissue or drainage. This ensures that the specimen reflects the true infecting organism rather than superficial bacteria.

Rationale for incorrect answers:

2. Swabbing for the specimen in the area with the largest collection of drainage: Swabbing drainage or pus leads to contamination from surface bacteria. The specimen should be taken from clean granulation tissue in the wound base after cleansing, not from exudate.

3. Removing crusts or scabs with sterile forceps and then culturing the site beneath: Crusts or scabs should only be removed if clinically indicated for wound care-not routinely for culture collection. The appropriate technique is to cleanse first, then rotate a sterile swab over a clean wound surface.

4. Waiting 8 hours following a dose of antibiotic to obtain the specimen: Culture collection should be performed before starting antibiotics, not several hours after. Waiting may reduce bacterial growth and yield inaccurate results.

Take-Home points

• Always cleanse the wound before obtaining a culture to remove contaminants.
• Collect the specimen from viable tissue, not drainage or crusted areas, for accurate identification of pathogens.

Nursing diagnoses help guide care planning by identifying actual or potential health problems. For clients with visible skin damage, such as excoriation, the correct diagnosis is Impaired Skin Integrity, reflecting an existing break in the epidermis or dermis. Understanding the distinction between “risk for” and “actual” problems ensures accurate assessment and appropriate intervention to promote healing and prevent complications like infection.

Rationale for correct answer:

2. Impaired Skin Integrity is the appropriate nursing diagnosis because excoriation means the epidermis has been damaged. This label applies when there is a disruption of the skin surface due to mechanical, chemical, or allergic causes.

Rationale for incorrect answers:

1. Risk for Impaired Skin Integrity: This diagnosis is used when the skin is still intact but there are factors that may lead to breakdown (e.g., immobility, incontinence, malnutrition). Since excoriation is already present, the risk has become an actual problem.

3. Impaired Tissue Integrity: This diagnosis is appropriate when damage extends into deeper tissues such as muscles, tendons, or bones. Excoriation from scratching affects only superficial skin layers (epidermis/dermis), not deeper tissues.

4. Risk for Infection: While infection is a related risk in excoriated skin, the primary problem is already impaired skin integrity. “Risk for Infection” may be a secondary diagnosis but not the most accurate primary one.

Take-home points

• “Impaired Skin Integrity” is used when there is actual skin damage, not just potential risk.
• Accurate nursing diagnoses ensure targeted interventions that support healing and prevent further complications.

Recognition of psychosocial responses to altered body image, is important especially in adolescents who are developmentally sensitive to appearance and peer perceptions. Nurses must distinguish between physical/tissue problems and emotional/psychological responses; appropriate diagnosis (Disturbed Body Image) guides interventions such as empathetic listening, normalization of feelings, education about healing and expected cosmetic outcomes, involvement of family, and referral to counseling or plastic/reconstructive services when appropriate.

Rationale for correct answer:

3. Disturbed Body Image: The adolescent’s statement reflects negative perceptions and emotional distress about appearance following facial injury and surgery. Disturbed body image captures feelings of altered self-concept and is the most appropriate nursing diagnosis to guide psychosocial interventions (support, therapeutic communication, referral).

Rationale for incorrect answers:

1. Pain: Pain is a physical experience and would be the correct diagnosis if the patient’s primary complaint was physical discomfort. The patient’s statement expresses self-image distress, not pain.

2. Impaired Skin Integrity: This could be a valid nursing diagnosis for the actual tissue injury (incision/wound across nose and cheek), but the patient’s verbalization (“I am so ugly now”) reflects psychosocial distress about appearance, so the priority diagnosis addressing her expressed concern is disturbed body image.

4. Disturbed Thought Processes: This diagnosis would be used for cognitive alterations (confusion, delusions, impaired judgment) - not appropriate here; the teen is cognitively coherent and expressing a normal emotional response to a change in appearance.

Take home points

1. Address expressed feelings first.
2. Treat both the physical injury (Impaired Skin Integrity) and emotional impact.

In normal wound-healing tissue versus signs of pathology; granulation tissue is a positive sign of healing-vascular, red, and bumpy-indicating that the wound bed is filling with new tissue. Distinguishing granulation from necrosis (eschar), exudate, or infected tissue is essential for appropriate wound management and dressing selection.

Rationale for correct answer:

4. Granulation tissue: Healthy granulation tissue appears reddish-pink, moist, and granular and indicates new capillary growth and connective tissue formation during the proliferative phase of healing.

Rationale for incorrect answers:

1. A sign of infection: Infection often presents with purulent drainage, increased pain, spreading erythema, warmth, and sometimes malodor or systemic signs. Reddish-pink, bumpy, moist tissue is not infection per se.

2. Eschar: Eschar is necrotic, dry, leathery, and dark (black or brown), not reddish-pink.

3. Exudate: Exudate refers to fluid (serous, sanguineous, purulent) draining from a wound, not tissue appearance.

Take home points

• Reddish-pink, moist, granular tissue - healthy granulation and a sign of wound healing.
• Accurate description of wound appearance (color, moisture, tissue type, drainage) guides appropriate dressing choices and interventions.

Identifying risk factors for pressure ulcer development, which are critical for prevention and early intervention. Pressure ulcers result from prolonged pressure, friction, shear, and moisture that impair skin perfusion. Older adults, especially those with limited mobility, incontinence, or painful conditions that restrict movement, are at highest risk. Early recognition allows nurses to implement preventive strategies such as repositioning schedules, moisture management, and pressure-relieving devices.

Rationale for correct answer:

2. The patient’s age of 86 years: Advanced age is a major risk factor because the skin becomes thinner, less elastic, and has reduced blood flow and subcutaneous fat, making it more susceptible to pressure injury.

3. Patient reports inability to control urine: Urinary incontinence contributes to moisture-associated skin breakdown, creating an environment that weakens the skin’s protective barrier and promotes bacterial growth.

4. A scheduled hip arthroplasty: Hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility

6. Patient reports increased pain in right hip when repositioning in bed or chair. Pain that limits mobility contributes significantly to pressure ulcer risk. If the patient avoids turning or shifting due to pain, pressure on certain areas becomes prolonged, leading to ischemia and tissue breakdown.

Rationale for incorrect answers:

1. The patient takes time to think about her responses to questions: Mild cognitive slowing is common in older adults and does not directly increase the risk for pressure ulcer formation unless accompanied by confusion or immobility. This finding alone is not a significant risk factor.

5. Lab findings include BUN 12 and creatinine 0.9: These are normal renal values, indicating adequate hydration and kidney function. They do not increase risk for pressure ulcer development.

Take home points

• Key pressure ulcer risk factors include immobility, incontinence, advanced age, poor nutrition, and decreased sensation or pain-limited movement.
• Prevention starts with early identification-implement repositioning, skin care, and nutritional support before breakdown occurs.

Medical Adhesive–Related Skin Injury (MARSI) occurs when adhesives damage the skin upon application or removal. MARSI prevention emphasizes gentle handling techniques, use of non-adhesive alternatives like Montgomery ties, and supportive products such as adhesive removers. Nurses must protect the skin barrier integrity, especially in elderly or fragile-skinned patients.

Rationale for correct answers:

1. Gently loosen and remove tape parallel to the skin: This technique minimizes trauma to the epidermis by reducing shear and tension on the skin surface during tape removal. Pulling tape away from the skin increases the risk of skin stripping, leading to MARSI (Medical Adhesive–Related Skin Injury).

3. Apply adhesive remover: Adhesive removers help dissolve adhesive residue and allow for gentle tape removal, reducing the risk of epidermal stripping or skin tears.

4. Use Montgomery ties to secure dressing: Montgomery ties reduce the need for repeated tape removal on the skin, thus preventing irritation and breakdown associated with frequent dressing changes.

Rationale for incorrect answers:

2. Change dressing only when saturated: Waiting until a dressing is saturated increases moisture exposure, which weakens skin integrity and promotes maceration-raising MARSI risk. Dressings should be changed per schedule or when compromised.

5. Immobilize area of wound: Immobilizing a wound site is not directly related to MARSI prevention. It may even hinder mobility and circulation, delaying healing.

Take home points:

• Always remove adhesive tape gently and parallel to the skin to prevent skin trauma.
• Reduce repeated tape use by opting for non-adhesive securing methods such as Montgomery ties or soft silicone dressings.

Pressure ulcer management is based on wound depth, tissue type, and exudate level. Maintaining a moist wound environment supports tissue regeneration and healing. Hydrocolloid dressings are preferred for partial-thickness ulcers because they keep the wound moist, protect from external contaminants, and promote autolytic debridement. Dressings should be selected to match wound characteristics and healing goals.

Rationale for correct answer:

3. Hydrocolloid: Hydrocolloid dressings maintain a moist wound environment, promote autolytic debridement, and protect the wound from contamination. They are ideal for partial-thickness, shallow pressure ulcers without necrosis or heavy exudate.

Rationale for incorrect answers:

1. Alginate: Alginate dressings are designed for moderate to heavy exudate and deeper wounds, as they absorb large amounts of drainage. They are not appropriate for shallow, partial-thickness ulcers with minimal exudate.

2. Dry gauze: Dry gauze can adhere to the wound bed and damage granulation tissue upon removal. It does not maintain a moist environment, which is essential for healing of partial-thickness wounds.

4. No dressing is indicated: Leaving the wound uncovered exposes it to friction, contamination, and drying. All pressure ulcers, even shallow ones, require protective coverage to promote healing.

Take-home points

• Hydrocolloid dressings are ideal for shallow, partial-thickness ulcers with minimal drainage.
• Maintaining a moist wound environment accelerates healing and reduces the risk of infection.

Shear occurs when underlying tissue moves in one direction while the skin remains fixed-commonly when patients slide down in bed. Reducing shear involves minimizing sliding friction, using assistive devices for movement, and maintaining bed angles that prevent downward drift. Nurses must combine proper positioning and movement techniques to protect fragile skin.

Rationale for correct answer:

1. Use a transfer device (e.g., transfer board): Transfer devices minimize friction and shear by allowing smooth movement instead of dragging skin against bed linens.

3. Have head of bed flat when repositioning patient: Keeping the bed flat reduces sliding and skin stretching, minimizing shear during repositioning.

5. Raise head of bed 30 degrees when patient is positioned supine: A semi-Fowler’s position (~30°) balances respiratory comfort with reduced shear risk; this is the recommended position for most immobile patients.

Rationale for incorrect answers:

2. Have head of bed elevated when transferring patient: Elevating the head of bed during transfer increases shear forces because the body slides down while the skin adheres to the surface.

4. Raise head of bed 60 degrees when patient is positioned supine: A high Fowler’s position (>45°) increases downward sliding and shear over the sacrum and coccyx.

Take home points

• Minimize sliding and friction: keep the bed as flat as possible when moving patients and use transfer devices.
• Shear prevention - less pressure injury; maintain a 30° head elevation when possible.

Skin protection in incontinent patients- prolonged exposure to urine or stool causes maceration, irritation, and breakdown that can lead to pressure ulcers or infection. Effective prevention includes maintaining cleanliness, using pH-balanced cleansers, applying protective barriers, and repositioning frequently. The goal is to maintain dry, intact, well-perfused skin while minimizing irritation.

Rationale for correct answer:

1. Frequent position changes: Repositioning decreases prolonged exposure of skin to moisture and pressure, promoting circulation and preventing skin breakdown.

4. Using an incontinence cleaner: pH-balanced, no-rinse cleansers are gentler than soap and water. They remove urine and feces effectively without damaging the skin’s protective barrier.

5. Applying a moisture barrier ointment: Moisture barriers (e.g., zinc oxide or dimethicone-based creams) protect skin from irritants and moisture, reducing the risk of dermatitis and pressure injury.

Rationale for incorrect answers:

2. Keeping the buttocks exposed to air at all times: While brief air exposure during cleansing and drying can help, keeping the area exposed “at all times” risks chilling, contamination, and infection.

3. Using a large absorbent diaper, changing when saturated: Diapers trap moisture and heat, increasing the risk of maceration and pressure injuries. Skin should be kept clean and dry, not enclosed in moisture-retaining materials.

Take home points

1. Moisture and pressure- skin breakdown - keep the skin clean, dry, and protected with moisture barriers.
2. Avoid occlusive materials (like diapers); reposition frequently and use gentle cleansers.

Prevention of pressure ulcers focuses on maintaining skin integrity, relieving pressure, and minimizing friction, moisture, and shear. Regular repositioning, use of pressure-relieving surfaces, and gentle skin care are essential. Nurses play a key role in early identification of risks using tools like the Braden Scale and implementing individualized preventive strategies.

Rationale for correct answer:

4. Using a mild cleansing agent when cleansing the skin: Gentle cleansing prevents skin irritation and maintains integrity, reducing the risk of skin breakdown. Harsh soaps strip natural oils and increase dryness and friction, predisposing the skin to pressure injury.

Rationale for incorrect answers:

1. Using waterproof material on the bed: Waterproof materials trap moisture and heat, increasing friction and maceration, which can lead to skin breakdown. Breathable materials are preferred.

2. Massaging any reddened area frequently: Massaging reddened areas can damage fragile capillaries in compromised skin, worsening tissue injury rather than preventing it.

3. Using an air-inflated ring to relieve pressure on areas: Air rings (donuts) can actually increase localized pressure and impair circulation to surrounding tissues, making ulcers more likely.

Take home points:

• Prevention of pressure ulcers starts with maintaining clean, dry, and intact skin using mild cleansers and proper repositioning.
• Avoid interventions that increase friction or pressure (e.g., massaging reddened skin, using rubber rings, or waterproof bedding).

Heat therapy is used to relieve pain, improve circulation, and promote tissue healing by causing vasodilation and increasing blood flow. However, if heat is applied for too long, a rebound effect occurs, resulting in vasoconstriction that decreases blood flow and may cause tissue damage. Safe heat therapy includes time-limited applications, appropriate temperature control, and regular skin assessment to prevent burns.

Rationale for correct answer:

1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). Prolonged heat application beyond 20–30 minutes causes a rebound phenomenon, where vasoconstriction replaces the initial vasodilation. This can decrease blood flow, increase tissue damage, and lead to burns or ischemia. Therefore, heating devices should not be used for more than 20–30 minutes at a time.

Rationale for incorrect answers:

2. It will be acceptable to leave the pad in place if the temperature is reduced: Lowering the temperature does not prevent the rebound effect or reduce the risk of burns. The duration, not just temperature, is critical in preventing tissue injury.

3. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed: Even if the skin looks normal, prolonged exposure can still damage deeper tissues. Heat should be removed after 30 minutes, then reapplied later if prescribed, with rest periods in between.

4. It will be acceptable to leave the pad in place as long as it is moist heat: Moist heat penetrates more deeply and increases the risk of burns. It should still be limited to 20–30 minutes to avoid tissue injury.

Take-Home points

• Limit heat application to 20–30 minutes to prevent the rebound phenomenon and tissue injury.
• Monitor skin integrity closely during and after heat therapy to identify early signs of burns or irritation.

Wound irrigation is the controlled flushing of a wound with a sterile or clean solution (usually normal saline) to remove debris, exudate, and bacteria, and to promote healing. Equipment typically includes gloves, a 35–60 mL syringe with an irrigation tip, and sterile solution. Maintaining appropriate pressure and temperature, and using clean or sterile technique depending on wound type, are key to preventing further tissue trauma or infection.

Rationale for correct answers:

1. Clean gloves: Clean gloves are acceptable for chronic or non-surgical wounds that are already colonized with bacteria, as irrigation is considered a clean (not sterile) procedure in these cases. They protect both nurse and client from contamination.

2. Sterile gloves: Sterile gloves are used when irrigating acute, surgical, or open wounds where sterility must be maintained. The nurse must follow facility policy and wound classification to determine whether sterile technique is necessary.

4. 60-mL syringe: A 60-mL syringe with an irrigation tip (often 19-gauge) is standard equipment. It delivers the right amount of pressure (4–15 psi) to remove debris and bacteria without damaging granulation tissue.

Rationale for incorrect answers:

3. Refrigerated irrigating solution: Irrigation solutions should be at room temperature to prevent vasoconstriction, tissue damage, or discomfort. Cold solutions reduce blood flow to the wound, delaying healing.

5. Forceps: They may be used in other wound care tasks (like debridement or dressing changes), but not specifically for irrigation.

Take-home points

• Room-temperature solution and gentle, pressurized irrigation promote effective cleansing and comfort.
• Use clean or sterile technique based on wound type-sterile for surgical wounds, clean for chronic ones.

A triangular arm sling supports the arm, immobilizes the shoulder or forearm, and promotes comfort after injury or surgery. Correct technique involves slightly flexing the elbow (<80°), keeping the hand elevated, supporting the wrist and hand fully, and positioning the knot off the neck’s midline to avoid spinal pressure. The nurse must also check circulation, skin condition, and comfort periodically to prevent complications.

Rationale for correct answer:

2. The knot is placed on either side of the vertebrae of the neck: The knot must be positioned off-center, either in front of or behind the neck, to avoid pressure on the spinal processes. Pressure directly on the vertebrae can cause pain, skin irritation, and possible nerve compression.

Rationale for incorrect answers:

1. The elbow is kept flexed at 90° or more: The elbow should be flexed slightly less than 80°, not 90° or more. This allows the hand to be elevated above the elbow, preventing dependent swelling and promoting venous return. Overflexion can cause discomfort and impede circulation.

3. The sling extends to just proximal of the hand: The sling should extend beyond the wrist, fully supporting the entire hand and wrist. This prevents venous pooling and reduces swelling. A sling ending before the hand fails to provide adequate support.

4. The sling is removed every 2 hours to check for circulation and skin integrity: While assessment of circulation, motion, and sensation (CMS) is necessary, every 2 hours is unnecessarily frequent and impractical for routine use. Checks are typically done at regular intervals (e.g., during nursing rounds or if swelling or discomfort is reported).

Take home points

• The knot should be off-center, avoiding pressure on the cervical vertebrae.
• The hand must be slightly elevated above the elbow with full wrist support to reduce swelling and ensure comfort.

Cold therapy (cryotherapy) used in nursing care to control inflammation, pain, and edema following injury or surgery. Cold application causes vasoconstriction, which decreases blood flow, limits inflammatory exudate formation, and reduces swelling and pain. It is typically used during the acute phase (first 24–48 hours) after injury to prevent excessive tissue damage and promote comfort.

Rationale for correct answer:

3. “I should see less swelling and redness with the cold treatment.” Cold therapy causes vasoconstriction, which limits inflammation, reduces capillary permeability, and minimizes swelling, redness, and pain.

Rationale for incorrect answers:

1. “I can expect to have more discomfort in the area where the cold is applied.” Cold application should reduce discomfort by numbing nerve endings and decreasing pain perception, not increase it.

2. “I should expect more drainage from the incision after the ice has been in place.” Cold causes vasoconstriction, which reduces blood flow and drainage, not increases it.

4. “My incision may bleed more when the ice is first applied.” Bleeding is reduced, not increased, because vasoconstriction limits blood flow to the area.

Take home points:

• Cold application reduces pain, swelling, and redness by causing vasoconstriction.
• Cold should not be applied for prolonged periods to prevent tissue ischemia or frostbite.

Use of abdominal binders in postoperative care provides support and stability to surgical incisions, particularly abdominal wounds, reducing tension on sutures and enhancing comfort during mobility or coughing. They are not drainage devices or treatments for edema. Correct application ensures comfort without restricting circulation or breathing.

Rationale for correct answers:

2. Provision of support to abdominal tissues when coughing or walking: The binder provides gentle, even pressure that supports weakened abdominal muscles, decreasing discomfort and the risk of wound dehiscence during movement or coughing.

4. Reduction of stress on the abdominal incision: The binder stabilizes the incision area, reducing tension on sutures and promoting healing by preventing wound separation.

Rationale for incorrect answers:

1. Collection of wound drainage: Binders do not collect drainage. Drainage is managed by surgical drains or dressings, not by external compression devices.

3. Reduction of abdominal swelling: While a binder provides mild compression, it is not primarily used to treat edema or swelling; excessive compression could impair circulation.

5. Stimulation of peristalsis (return of bowel function) from direct pressure: Binders do not stimulate peristalsis. Early ambulation and adequate hydration are the preferred methods for promoting bowel function postoperatively.

Take home points

• Abdominal binders - support and incision protection, not drainage or bowel stimulation.
• Always ensure the binder is snug but not tight, allowing normal breathing and circulation.

Pressure injury prevention focuses on reducing prolonged pressure, maintaining skin integrity, and ensuring adequate nutrition and hydration. Regular repositioning every 2 hours, using pressure-relieving devices, and keeping skin clean and moisturized are key nursing measures. Early recognition of redness or skin changes allows prompt intervention before ulcers develop.

Rationale for correct answer:

3. “If my father cannot turn himself in bed, I should help him change position every 4 hours.” Clients who cannot turn themselves should be repositioned every 2 hours, not every 4 hours, to prevent pressure ulcer formation.

Rationale for incorrect answers:

1. “If a skin area gets red but then the red goes away after turning, I should report it to the nurse.”
This statement reflects good understanding. Redness that resolves after pressure relief indicates transient hyperemia, not a pressure ulcer, but it’s still appropriate to monitor and report it for early prevention.

2. “Putting foam pads under my heels or other bony areas can help decrease pressure.”
Foam pads or heel protectors are commonly used to reduce pressure on vulnerable areas. Bony prominences like heels, sacrum, and elbows are high-risk zones. Offloading pressure with foam or pillows helps prevent skin breakdown.

4. “The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.” Warm (not hot) water prevents drying, and applying lotion to damp skin helps maintain hydration and protect against breakdown.

Take-home points

• Clients unable to move independently must be repositioned at least every 2 hours.
• Preventive skin care, including moisturizing and pressure relief, is the cornerstone of avoiding pressure injuries.

During the normal phases of wound healing, particularly the inflammatory phase occurs within the first 1–3 days after surgery. During this stage, the body mounts an immune response to injury, characterized by local redness, heat, swelling, pain, and mild systemic responses like low-grade fever and malaise. These findings represent normal, expected healing processes rather than infection. Recognizing the difference between normal inflammation and pathologic infection helps nurses avoid unnecessary interventions and anxiety for the client.

Rationale for correct answer:

1. Document the findings and continue to monitor the patient: Slight elevation in temperature, redness, pain, and mild malaise 36 hours after surgery are expected signs of the inflammatory phase of wound healing, not infection. The inflammatory phase usually occurs from the time of injury up to about the third day postoperatively.

Rationale for incorrect answers:

2. Administer antipyretics, as ordered: Fever is mild and expected during the inflammatory phase, so routine administration of antipyretics may interfere with the natural healing response unless fever exceeds the normal expected range (>38°C) or causes discomfort.

3. Increase the frequency of assessment to every hour and notify the patient’s physician: These findings do not require emergency notification. Hourly assessments are excessive unless the client’s condition deteriorates.

4. Increase the frequency of wound care and contact the physician for an antibiotic order: There is no indication of infection (e.g., purulent drainage, spreading erythema, or persistent high fever). Early inflammation does not require antibiotics.

Take home points:

• Mild redness, warmth, and low-grade fever 24–48 hours after surgery are normal signs of the inflammatory phase of healing-not infection.
• The appropriate nursing action is to document and monitor these findings, intervening only if symptoms worsen or signs of infection (purulent drainage, high fever, spreading erythema) develop.

Wound dehiscence and evisceration is a postoperative emergency in which internal organs protrude through a surgical incision. The priority nursing actions include reducing intra-abdominal pressure (low Fowler’s position), protecting exposed organs with sterile saline-moistened dressings, and immediately notifying the surgeon. Prompt recognition and correct sequence of interventions prevent tissue necrosis, infection, and further complications while preparing the patient for surgical repair.

Rationale for correct answer:

3. Place the patient in the low Fowler’s position: The immediate action is to reduce strain on the abdominal wound. Placing the patient in a low Fowler’s or semi-recumbent position with the knees slightly flexed decreases tension on the incision and prevents further evisceration of abdominal contents. This position also enhances comfort and reduces intra-abdominal pressure.

2. Cover the exposed tissue with sterile towels moistened with sterile NSS: Once the client is positioned safely, the nurse should protect the protruding organs. Sterile normal saline–moistened dressings or towels keep the viscera from drying out and reduce the risk of infection. Using sterile technique is essential to prevent contamination of the abdominal contents.

1. Notify the physician immediately of the situation: After protecting the wound and ensuring the patient’s safety, the nurse must promptly contact the surgeon for emergency surgical intervention. Dehiscence with evisceration is a surgical emergency, and rapid communication ensures the client is prepared for operative repair.

Knowledge of basic infection-prevention priorities in wound care is important. While sterile technique, appropriate supplies, good nutrition, and topical agents all play roles, hand hygiene is the cornerstone of preventing wound contamination and healthcare-associated infection. Consistent hand hygiene by all caregivers and visitors-combined with aseptic technique during dressing changes-provides the highest protection.

Rationale for correct answer:

4. Performing careful hand hygiene: Hand hygiene (soap & water or alcohol-based rub) is the single most effective measure to prevent healthcare-associated infections. Clean hands before and after wound contact prevent transfer of pathogens to the wound and reduce overall infection rates.

Rationale for incorrect answers:

1. Using sterile dressing supplies: Sterile supplies reduce contamination risk during dressing changes, but if hand hygiene is poor, supplies can still become contaminated. Supplies are important, but they are one part of the bundle of infection-prevention practices.

2. Suggesting dietary supplements: Improved nutrition (including adequate protein, vitamins) supports wound healing and immune function over time, but dietary supplements alone do not directly prevent microbial transmission to the wound at bedside.

3. Applying antibiotic ointment: Topical antibiotics may be used selectively for contaminated wounds or as ordered, but routine use can promote resistance and may mask signs of infection. They are not more effective than basic infection-control measures.

Take home points

• Hand hygiene is the single most effective action to prevent wound and other healthcare-associated infections.
• Use hand hygiene plus a bundle of measures (aseptic technique, clean environment, good nutrition, appropriate dressing choices) for best wound-infection prevention.

Before performing any sterile procedure, assessment is used to determine wound condition, guide technique, and prevent unnecessary trauma. Proper positioning first, aseptic technique, and irrigation direction (“clean to dirty”) are all critical for preventing infection and promoting healing

Rationale for correct answer:

2. Position the patient so the irrigation solution will flow from clean to dirty: Proper positioning ensures that irrigation fluid flows from the least contaminated (clean) area to the most contaminated (dirty) area, minimizing spread of microorganisms.

Rationale for incorrect answers:

1. Direct a stream of solution into the wound: This is part of the irrigation procedure itself, but it should not be the first step. Directing solution prematurely could cause trauma or dislodge healthy tissue.

3. Assess the wound and surrounding tissue: Positioning should occur before beginning the actual procedure to limit the amount of time the wound is exposed. Then assessment guides whether irrigation is appropriate, the technique to use, and helps establish a baseline for documenting wound progress.

4. Put on sterile gloves: Sterile gloves are applied later, after wound assessment and setup of sterile supplies. The nurse first performs assessment with clean gloves, then sets up the sterile field and dons sterile gloves for the irrigation itself.

Take home points

• Always assess before performing any sterile or invasive procedure.
• During irrigation, direct the solution from clean to dirty areas using sterile technique to prevent cross-contamination and infection.

Negative Pressure Wound Therapy (NPWT), is an advanced wound management system that applies controlled suction to a sealed wound dressing. The vacuum-assisted pressure removes excess fluid, reduces edema, promotes circulation, and enhances granulation tissue development, all of which facilitate wound healing. Maintaining a moist wound environment under sub-atmospheric pressure promotes faster tissue regeneration and reduces wound size.

Rationale for correct answer:

3. The therapy provides a moist environment and stimulates blood flow to the wound: NPWT (also called wound VAC) uses controlled suction to remove exudate, maintain a moist environment, and enhance tissue perfusion and granulation tissue formation.

Rationale for incorrect answers:

1.The therapy is used to collect excess blood loss and prevent the formation of a scab: NPWT removes excess exudate, not blood, and does not focus on scab prevention.

2. The therapy will prevent infection, ensuring the wound heals with less scar tissue: NPWT reduces bacterial load and promotes healing, but it does not guarantee infection prevention or minimal scarring.

4. The therapy irrigates the wound to keep it free from debris and excess wound fluid: NPWT does not irrigate the wound; instead, it continuously removes wound exudate and debris through negative pressure.

Take home points:

• NPWT promotes healing by maintaining moisture, stimulating perfusion, and encouraging granulation tissue formation.
• It is not a wound irrigation system and does not eliminate infection risk but helps reduce bacterial burden and exudate accumulation.

Risk factors and mechanisms that cause pressure injuries include key mechanical factors like pressure (sustained compression), shear (sliding forces that stretch and occlude blood vessels), and friction (rubbing that damages superficial skin). Other contributing risks include immobility, impaired sensation, moisture, malnutrition, edema, and comorbidities. In a patient who sits and slumps, shear (often combined with friction) is a principal mechanism producing tissue damage-particularly over the sacrum and ischial tuberosities.

Rationale for correct answer:

2. Shearing forces: Slumping in a chair causes the skin and subcutaneous tissues to move relative to underlying bone and muscle (shear), especially over the sacrum and coccyx; shear distorts blood vessels and greatly increases risk of pressure injury even without prolonged vertical pressure alone.

Rationale for incorrect answers:

1. Malnutrition: Malnutrition increases overall vulnerability to pressure injury (thin skin, poor healing), but the question’s scenario (sitting and slumping) points more directly to mechanical forces.

3. Edema: Edema can increase tissue vulnerability and impair perfusion, but it’s not the direct mechanical cause produced by slumping.

4. A chronic disease: Chronic illness may predispose to pressure injury via immobility, poor perfusion, or malnutrition, but the positional shearing from slumping is the most immediate and likely factor.

Take home points:

• Slumping/poor positioning- shear is a high-risk mechanical cause of pressure injuries and must be prevented with positioning, cushions, and frequent repositioning.
• Address both mechanical risks (pressure, shear, friction) and patient factors (nutrition, moisture, mobility) when doing pressure-injury prevention.

Pressure ulcer staging, is based on the depth and extent of tissue damage. Stage I involves intact skin with non-blanchable erythema; Stage II involves partial-thickness loss (abrasion or blister); Stage III involves full-thickness loss with subcutaneous fat visible; and Stage IV involves full-thickness loss with exposed muscle, bone, or tendon. Accurate staging ensures appropriate documentation, intervention, and evaluation of healing progress.

Rationale for correct answer:

2. An open lesion with full-thickness tissue loss and visible subcutaneous fat: Stage III pressure ulcers involve full-thickness skin loss, extending into the subcutaneous tissue but not exposing bone, tendon, or muscle. Fat may be visible, and slough may be present.

Rationale for incorrect answers:

1. Redness that persists when pressure is relieved: This describes a Stage I pressure ulcer, where the skin remains intact but shows non-blanchable redness over a bony prominence.

3. A necrotic area extending through the fascia to bone: This represents a Stage IV ulcer, where there is full-thickness tissue loss with exposed bone, tendon, or muscle and often necrosis.

4. A reddened area with an abrasion and pain: This describes a Stage II ulcer, involving partial-thickness skin loss such as a blister, abrasion, or shallow crater.

Take home points:

• Stage III - full-thickness skin loss with visible fat, not bone or muscle.
• Accurate ulcer staging guides treatment - misclassification can delay proper wound care and increase complications.

Proper wound cleaning requires starting from the cleanest area (the center) and moving outward to avoid introducing contaminants. Preparing sterile equipment, using the prescribed solution, and maintaining patient understanding are critical steps. For dehisced wounds, meticulous technique prevents infection and promotes healing by maintaining a clean wound environment and protecting surrounding skin.

Rationale for correct answer:

4. Explain the procedure to the patient: The nurse should always begin by explaining the procedure to ensure informed cooperation, reduce anxiety, and promote patient comfort and understanding.

2. Moisten sterile gauze or swab with prescribed cleansing agent: Preparing sterile supplies ensures that cleaning is performed under aseptic conditions and with the appropriate solution (e.g., normal saline or antiseptic as ordered).

1. Clean the wound in full or half circles, beginning in the center and working toward the outside: This cleaning method moves from least contaminated to most contaminated areas, reducing the risk of introducing microorganisms into the wound bed.

3. Clean to at least 1 inch beyond the end of the new dressing: This ensures that the surrounding skin is clean and that the new dressing adheres to uncontaminated tissue, helping prevent infection.

Take home points:

• Always explain before you clean - patient cooperation and aseptic preparation are essential first steps.
• Clean from center to periphery to prevent contamination and always extend cleaning beyond dressing borders for full protection.

When pressure is applied to bony prominences, local ischemia may occur. If redness blanches with fingertip pressure, perfusion has returned - this is called blanchable hyperemia, a reversible stage. If redness does not blanch, it signals non-blanchable erythema, the first stage of pressure injury. Early recognition of blanching responses helps nurses intervene promptly and prevent progression to true ulcers.

Rationale for correct answer:

4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode: When redness blanches (turns white when pressed) and then returns to red, this shows reactive hyperemia, a normal physiological response where blood flow returns after pressure is relieved - not a pressure ulcer yet.

Rationale for incorrect answers:

1. A local skin infection requiring antibiotics: Infection is characterized by warmth, swelling, drainage, pain, or systemic signs such as fever, not blanchable redness.

2. Sensitive skin that requires special bed linen: While sensitive skin may need gentle care, blanchable redness is not a sign of skin sensitivity; it indicates temporary ischemia that is resolving.

3. A Stage 3 pressure injury needing the appropriate dressing: Stage 3 ulcers involve full-thickness skin loss with visible fat. Blanchable redness means tissue perfusion is still intact, and no ulceration has occurred.

Take home points:

• Blanchable redness - reversible (body restoring blood flow); non-blanchable redness = Stage I pressure injury.
• Frequent repositioning and skin assessment are key nursing interventions to prevent pressure ulcer formation.

Wound dehiscence with evisceration is a life-threatening complication in which surgical incision edges separate and abdominal contents protrude. Immediate priorities are to protect exposed viscera (keep them sterile, warm, and moist), prevent further contamination/ischemia, call for surgical intervention, and support the patient hemodynamically. Timely nursing actions reduce complications and improve surgical outcomes.

Rationale for correct answers:

1. Notify the health care provider: Evisceration is a surgical emergency. The surgeon must be notified immediately so the patient can be prepared for emergency return to the operating room. The nurse should also call for help, place the patient NPO, and prepare IV access and resuscitative measures as ordered.

4. Cover the area with sterile, saline-soaked towels immediately: The immediate goal is to protect the exposed bowel, keep it warm and moist, decrease contamination and reduce risk of ischemia. Sterile saline-moistened towels (or dressings) are the standard immediate intervention while arranging urgent surgical repair.

Rationale for incorrect answers:

2. Allow the area to be exposed to air until all drainage has stopped: Exposing eviscerated bowel to air increases desiccation, cooling, contamination and risk of infection and ischemia. The bowel must be kept moist and protected until surgical repair.

3. Place several cold packs over the area, protecting the skin around the wound: Cold packs are not appropriate. They may reduce perfusion and increase risk of ischemia to exposed viscera. Do not apply cold to eviscerated bowel.

5. Cover the area with sterile gauze and apply an abdominal binder: Covering the exposed bowel with sterile, saline-moistened gauze is correct. Applying a tight abdominal binder a tight binder that increases intra-abdominal pressure or compromises circulation. The priority remains sterile, moist coverage and rapid surgical consultation.

Take home points

• Cover exposed bowel with sterile saline-soaked towels and call the surgeon immediately - this is the single most urgent nursing response.
• Do not expose the bowel to air, do not reinsert viscera, and avoid tight compression; stabilize the patient and prepare for emergency surgery.

Safe, effective irrigation requires preparation (equipment and waste disposal), aseptic technique, correct fluid and device assembly, proper positioning, and controlled irrigation pressure and direction. Following the correct sequence reduces contamination, prevents injury to granulating tissue, and promotes wound healing.

Rationale for correct answer:

4. Place biohazard bag near bed: First step (preparation). Set up a safe work area and disposal for contaminated fluid and materials before starting the procedure.

3. Fill syringe with irrigation fluid: Preparation step that must occur before attaching the catheter and irrigating. Use prescribed solution (usually normal saline) and the correct volume.

2. Attach 19-gauge angiocatheter to syringe: Must be done after the syringe is filled and before positioning. The angiocatheter (or irrigation tip) converts the syringe into an effective irrigator for appropriate pressure and flow.

5. Position angiocatheter over wound: Do this immediately prior to irrigation. Proper positioning (slight distance above wound, directing flow from least to most contaminated areas or as ordered) ensures effective cleansing and minimizes tissue trauma.

1. Use slow, continuous pressure to irrigate wound: After preparation and positioning, irrigation is done using a steady, controlled pressure (often a 35-mL syringe with appropriate catheter or a pressurized system) to remove debris without damaging healthy tissue.

Take home points

• Prepare before you flush: set up disposal, fill syringes with the correct solution, and assemble the irrigation device before positioning and irrigating.
• Irrigate with controlled, continuous pressure and correct direction to remove debris while protecting healthy tissue (avoid high-pressure streams that damage tissue).

Wound management and debridement, is a critical step in promoting healing of chronic or non-healing wounds. Removing necrotic or devitalized tissue decreases infection risk and stimulates healthy tissue regeneration. Debridement is often a prerequisite before advanced wound care techniques are initiated.

Rationale for correct answer:

1. Debridement: This is the medical removal of dead, damaged, or infected tissue to promote wound healing. It reduces bacterial load, stimulates granulation, and allows for better assessment of viable tissue. Methods include surgical, enzymatic, autolytic, or mechanical debridement.

Rationale for incorrect answers:

2. Pressure distribution: Refers to repositioning or padding to prevent pressure ulcers. It does not involve tissue removal.

3. Negative-pressure wound therapy (NPWT): Uses controlled suction to promote wound healing by drawing out fluid and increasing perfusion but does not remove dead tissue directly.

4. Sanitization: Refers to cleaning surfaces or instruments to reduce microorganisms-not a wound care intervention.

Take home points:

• Debridement is essential for removing necrotic tissue and promoting wound healing.
• Always assess wound type and patient condition before selecting the debridement method (e.g., surgical, enzymatic, or autolytic).

Medical Device–Related Pressure Injuries (MDRPIs) are injuries that occur when medical devices exert continuous pressure on skin or mucosa, often in patients requiring oxygen therapy, IV lines, or immobilization devices. Nurses play a key role through regular skin assessments, device repositioning, and pressure redistribution techniques.

Rationale for correct answers:

2. Cushion at-risk areas (ears, nose, etc.): Foam or protective dressings distribute pressure evenly and reduce friction between the device and skin, preventing pressure injury at high-risk contact points.

3. Choose correct size of device: Properly fitting devices (e.g., oxygen masks, tubing, cervical collars) minimize unnecessary pressure or friction on the skin, lowering MDRPI risk.

4. Observe for erythema or irritation that conforms to device shape: Skin redness or breakdown that mirrors the shape of a device indicates an MDRPI. Early detection allows for timely removal or repositioning of the device.

5. Observe under casts and splints: Even though these are rigid medical supports, pressure injuries can form beneath them. Frequent skin assessment where possible prevents unnoticed breakdown.

Rationale for incorrect answers:

1. Assess skin under devices every 2 hours: Individualize the frequency of pressure checks for each patient and base your assessment on the response of the skin to the external pressure.

Take home points:

• Always inspect skin under and around medical devices frequently to identify early injury signs.
• Use padding and proper device sizing to prevent localized pressure and friction.

The skin acts as the body’s first line of defense, a sensory organ, and a key player in maintaining homeostasis by regulating body temperature and fluid balance.

Rationale for correct answer:

2. Protection, sensory perception, and temperature regulation: The skin protects against pathogens and mechanical injury, perceives sensory stimuli (touch, pain, temperature), and regulates body heat through vasodilation, vasoconstriction, and sweating.

Rationale for incorrect answers:

1. Support, nourishment, and sensation: While the skin offers limited support and sensation, nourishment is not a direct function of the skin. It serves more as a barrier and regulator.

3. Fluid transport, sensory perception, and aging regulation: The skin maintains fluid balance but does not transport fluid or regulate aging processes directly.

4. Support, protection, and communication: While facial expression can communicate emotion, “communication” is not a primary physiologic function of the skin.

Take home points:

• The skin’s three core functions are protection, sensation, and temperature regulation.
• Skin integrity is essential to maintaining the body’s defense against infection and fluid loss.