When evaluating a patient with a suspected stage 1 pressure ulcer, which intervention is most appropriate to prevent progression?
Apply a hydrocolloid dressing.
Implement a turning schedule every 2 hours.
Debride the area to remove necrotic tissue.
Apply antibiotics topically.
The Correct Answer is B
A. Apply a hydrocolloid dressing: This is an acceptable intervention for protection but is not the most appropriate intervention to prevent progression. The most critical step is relieving pressure.
B. Implement a turning schedule every 2 hours: A Stage 1 pressure injury is defined as nonblanchable erythema on intact skin. The underlying cause is unrelieved pressure. The single most effective intervention to prevent progression to deeper stages is to immediately eliminate that pressure by implementing a regular turning and repositioning schedule (or repositioning the patient immediately, if found off-schedule).
C. Debride the area to remove necrotic tissue: A Stage 1 pressure injury has intact skin and, by definition, does not have necrotic tissue (eschar or slough) that requires debridement.
D. Apply antibiotics topically: A Stage 1 pressure injury is an injury due to pressure, not an infection. Topical antibiotics are not indicated unless there is clinical evidence of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cover the wound with a dry sterile dressing: This is the most appropriate action among the choices, assuming the bleeding is minor and the wound needs dressing. A dry sterile dressing protects the wound from contamination and provides a surface for clot formation, which is essential to stop minor capillary bleeding. If the drainage is significant (potential hemorrhage), the best action would be to apply pressure over the dressing and notify the provider, but simply covering it with a sterile dressing is a necessary initial step in wound management.
B. Document the drainage and continue routine wound care:While documentation is necessary, bright red blood is a deviation from normal for most healing wounds and requires intervention beyond routine care, such as assessing vital signs and applying pressure, to ensure it stops.
C. Apply a warm compress to the wound site: A warm compress causes vasodilation, which would increase blood flow and worsen active bleeding.
D. Apply a cold compress to the wound site: While cold causes vasoconstriction which could reduce bleeding, it can also impair the circulation to the wound, potentially causing tissue damage. Direct pressure is the preferred method to stop bleeding.
Correct Answer is D
Explanation
A. Presence of slough or eschar: Both Stage 2 and Stage 3 injuries may eventually develop some slough if they deteriorate or if they are mismanaged. However, slough and eschar are defining characteristics of an unstageable injury if they obscure the wound base. A clean Stage 2 injury will not have slough or eschar.
B. Nonblanchable erythema: Nonblanchable erythema is the defining characteristic of a Stage 1 pressure injury, which involves intact skin. Stage 2 and Stage 3 both involve skin loss.
C. Exposed muscle or bone: Exposed muscle or bone indicates a Stage 4 pressure injury.
D. Partial-thickness skin loss: A Stage 2 pressure injury is defined by partial-thickness loss of the dermis. A Stage 3 pressure injury is defined by full-thickness tissue loss involving the subcutaneous fat. This difference in thickness is the key distinction.
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