Which patient is at highest risk for developing a stage 1 pressure ulcer?
A patient with adequate hydration and skin care regimen.
An immobile patient with poor nutritional status.
A mobile patient with a history of diabetes.
A patient who regularly changes position every hour.
The Correct Answer is B
A. A patient with adequate hydration and skin care regimen. Adequate hydration and a good skin care regimen are preventive measures that significantly decrease the risk of developing a pressure injury.
B. An immobile patient with poor nutritional status. Immobility (prolonged, unrelieved pressure and shear) is the primary mechanical cause of pressure injuries. Poor nutritional status (specifically, low protein and poor hydration) compromises the integrity of the skin and the body's ability to repair tissue, drastically multiplying the overall risk.
C. A mobile patient with a history of diabetes. While diabetes is a risk factor due to poor circulation and neuropathy, a mobile patient can independently relieve pressure, which is the most critical factor in prevention. Therefore, they are at a lower risk than an immobile patient.
D. A patient who regularly changes position every hour. Regular repositioning (typically every two hours in bed, or more frequently in a chair) is the single most effective intervention for preventing pressure injuries. This patient is actively mitigating their risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Offload pressure from the heel using a foam wedge:A DTPI signifies deep tissue damage due to intense and/or prolonged pressure and shear. The priority is to eliminate the source of pressure completely (offload the heel) using appropriate devices like heel protectors or foam wedges to prevent progression of the injury to a deep open wound.
B. Massage the area gently to increase circulation: Massaging a discolored area, especially one suspected of having deep tissue injury, can cause further shearing forces and damage to the already compromised underlying capillaries and tissues.
C. Apply ice packs to reduce discoloration: Ice causes vasoconstriction, which would further restrict the already impaired blood flow to the ischemic tissue, worsening the injury.
D. Apply transparent dressing to the area:While a transparent dressing may be used for protection, it does nothing to relieve the underlying pressure causing the injury. Pressure relief is the priority.
Correct Answer is C
Explanation
A. Apply a dry sterile dressing to the wound: While a dressing is needed, a dry dressing can adhere to the exposed tissues. The wound should be covered with a moist, sterile dressing to protect the open tissue.
B. Apply an antibiotic ointment directly to the open wound: Dehiscence is a mechanical failure, not an infection (at this stage). Topical antibiotics are not the initial priority and may irritate the wound.
C. Notify the healthcare provider immediately: This is the most appropriate initial nursing action. Wound dehiscence is a serious surgical complication that requires prompt evaluation by the surgeon. The nurse must immediately stabilize the patient and the wound and communicate the critical finding to the provider for repair or management planning.
D. Encourage the patient to ambulate to improve circulation: Ambulation, physical exertion, or straining (e.g., coughing, bending) could further separate the wound edges, potentially leading to a much more severe evisceration. The patient should be kept calm and placed in a position to minimize tension on the wound.
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