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Pressure Ulcer NCLEX Questions
1. One of the most important ways to prevent pressure ulcers is to:?
A. Do regular skin assessments.
B. Provide support surfaces for all
C. Identify at-risk individuals
D. Do regular repositioning.
2. You are assigned five patients on your nursing unit. Which patient is at most risk for pressure ulcers ?
A. A 73 year old female weighing 82 lbs with stress incontinence and dementia.
B. A 90 year old male with Congestive Heart Failure who has 3+ pitting edema in lower extremities
C. A 6 month old with the flu.
D. An ambulatory 88 year old with dementia who is admitted with shingles.
3. All at-risk patients should be assessed for pressure ulcers:
A. At time of admission
B. At regular intervals
C. At any significant change of health condition.
D. Upon discharge.
4. During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound?
A. A. Area is red and does not blanch
B. . Full-thickness skin loss to dermis and subcutaneous tissues.
C. Partial thickness of dermis with shallow open ulcer
D. Full thickness with bone and tendon visible.
5. In acute care, reassessment for pressure ulcers should occur how often?
A. Every 24 to 48 hours
B. Weekly initially, then monthly
C. Every shift
D. After the patient dies
6. In home care, reassessment for pressure ulcers should occur how often?
A. Every 24 to 48 hours
B. Weekly initially, then monthly
C. Every nurse visit
D. Every fourth nurse visit
7. While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be?
A. Stage 1 pressure injury
B. Deep-tissue injury .
C. Stage 4 pressure injury
D. Stage 2 pressure injury
8. How would you as the nurse stage figure 3:
A. Stage 1.
B. Stage 2.
C. Stage 3.
D. Unstageable
9. Which of the following factors can cause pain when a patient or resident has a pressure ulcer ?
A. Pressure, friction, and shear
B. Damaged nerve endings
C. Inflammation insertion
D. Infection
10. You receive report that your patient who will be admitted to your unit has a stage 4 pressure injury. Which figure above represents this type of injury