Question

The nurse teaches a caregiver about preventing pressure ulcers. How does the nurse explain their cause?

Answer 1

Correct Answers:

Pressure ulcers are caused by occlusion of arterial vessels to a tissue area

Rationale :

🔷 Pressure ulcers develop when prolonged pressure compresses blood vessels supplying tissue.

🔷 This pressure reduces oxygen and nutrient delivery to the skin and underlying tissue.

🔷 When tissue perfusion is decreased for a prolonged time, ischemia occurs.

🔷 Continued ischemia leads to cell death, skin breakdown, and ulcer formation.

🔷 Common sites include bony prominences such as the sacrum, heels, hips, and elbows.

Pressure ulcers are caused by venous stasis surrounding a flesh area

🔷Venous stasis causes pooling of blood and can contribute to venous ulcers, especially in the lower legs.

🔷 Pressure injuries are primarily caused by prolonged pressure that reduces tissue perfusion.

Pressure ulcers are caused by fibrous collagen growth with immobility

🔷Fibrous collagen growth is associated with scar tissue formation and wound healing.

🔷It is not the main cause of pressure ulcer formation.

Pressure ulcers are caused by anaerobic bacteria pooling on the skin

🔷Bacteria can infect an existing wound, but they do not cause the initial pressure injury.

🔷The primary cause is pressure-related ischemia.

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Answer 2

Correct Answers:

Stage 2 Pressure Injury

Rationale :

🔷 A stage 2 pressure injury involves partial-thickness skin loss with exposed dermis.

🔷 The wound in the illustration appears red, shallow, moist, and open, which is consistent with loss of the superficial skin layer.

🔷 Stage 2 pressure injuries can also appear as an intact or ruptured serum-filled blister.

🔷 The injury does not show visible fat, muscle, tendon, or bone, so it is not a deeper-stage wound.

🔷 The nurse should protect the area, reduce pressure, manage moisture, and promote wound healing.

Stage 3 Pressure Injury

🔷A stage 3 pressure injury involves full-thickness skin loss with visible adipose tissue.

🔷The image does not show deep tissue loss or exposed subcutaneous fat.

Stage 1 Pressure Injury

🔷A stage 1 pressure injury has intact skin with nonblanchable redness.

🔷The illustration shows superficial skin breakdown, making it more advanced than stage 1.

Stage 4 Pressure Injury

🔷A stage 4 pressure injury involves exposed bone, tendon, ligament, cartilage, fascia, or muscle.

🔷These deep structures are not visible in the illustration.

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Answer 3

Correct Answers:

It must be checked/compared to the physician's order by 2 licensed nurses.

Rationale :

🔷 TPN is a high-alert nutritional infusion because it contains concentrated dextrose, amino acids, electrolytes, vitamins, and other additives.

🔷 It must be verified carefully against the provider’s prescription to prevent serious complications such as hyperglycemia, electrolyte imbalance, or fluid overload.

🔷 The safest rule is that two licensed nurses compare the TPN label with the order before hanging the bag.

🔷 This double-check helps confirm the correct client, formula, rate, additives, and expiration time.

🔷 TPN is usually administered through a central line using an infusion pump and strict aseptic technique.

It must be checked compared to the physician’s order by any 2 people.

🔷Any two people are not appropriate because TPN verification requires licensed clinical judgment.

🔷Unlicensed personnel cannot independently verify high-alert IV therapy.

It must be checked/compared to the physician’s order by an RN and pharmacist.

🔷The pharmacist prepares or verifies the TPN before it reaches the unit, but bedside hanging requires nursing verification.

🔷Facility policy typically requires two licensed nurses.

The physician must come to the bedside and hang the TPN him/herself.

🔷Physicians prescribe TPN but do not routinely hang it at the bedside.

🔷Hanging and monitoring TPN is a nursing responsibility.

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Answer 4

Correct Answers:

Verify the bulb remains compressed, document the finding, and continue to monitor

Rationale :

🔶 A Jackson-Pratt drain works by creating gentle suction when the bulb is compressed.

🔶 Decreased drainage can be expected as the wound begins healing and fluid accumulation lessens.

🔶 The nurse should first verify that the bulb remains compressed and functioning properly.

🔶 If the drain is patent, the tubing is not kinked, and there are no signs of infection or swelling, the finding should be documented and monitored.

🔶 Sudden absence of drainage with pain, swelling, or loss of suction would require further action.

Notify the surgeon of a possible blockage and wait for orders.

🔶This is not the first action if the drain appears functional and drainage is simply decreasing.

🔶The nurse should assess the drain system before assuming blockage.

Replace the drain and notify the provider.

🔶Nurses do not replace JP drains independently.

🔶Drain replacement is a provider-managed procedure.

Remove the drain and notify the provider.

🔶The nurse should not remove a JP drain without a prescription.

🔶Removing it could interrupt wound healing and increase risk for fluid accumulation.

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Answer 5

Correct Answers:

Instruct a staff member to notify a surgeon STAT
Obtain and monitor vital signs
Position the patient with knees flexed
Cover with moistened sterile dressings or sterile drape

Rationale :

Instruct a staff member to notify a surgeon STAT

🔷 Evisceration is a surgical emergency because internal organs protrude through the wound opening.

🔷 The surgeon must be notified immediately because the client usually requires urgent operative repair.

🔷 Delegating notification allows the nurse to remain at the bedside and protect the exposed tissue.

🔷 Rapid communication helps prevent tissue drying, infection, shock, and further wound separation.

🔷 The nurse should stay with the client and continue emergency wound protection.

Obtain and monitor vital signs

🔷 Vital signs help identify early signs of shock, bleeding, infection, or physiologic instability.

🔷 Evisceration can cause anxiety, pain, fluid loss, and circulatory compromise.

🔷 Monitoring blood pressure, pulse, respiratory rate, oxygen saturation, and temperature helps guide urgent care.

🔷 Changes in vital signs should be reported promptly to the provider.

🔷 Continued assessment is essential until surgical intervention occurs.

Position the patient with knees flexed

🔷 The client should be placed in a low-Fowler’s or supine position with knees flexed.

🔷 Flexing the knees decreases tension on the abdominal incision.

🔷 Reduced abdominal strain helps prevent further protrusion of abdominal contents.

🔷 This position also promotes comfort and limits pulling on the wound edges.

🔷 The goal is to protect the exposed organs and reduce pressure on the incision.

Cover with moistened sterile dressings or sterile drape

🔷 The exposed organs must be covered with sterile dressings moistened with normal saline.

🔷 Moist sterile coverage prevents tissue drying and decreases contamination risk.

🔷 The nurse should avoid applying pressure directly to the exposed bowel.

🔷 Maintaining moisture helps preserve tissue viability until surgical repair.

🔷 This is one of the most important immediate nursing actions.

Attempt to push the bowel back into the abdominal cavity.

🔷The nurse should never attempt to reinsert exposed organs.

🔷This can cause tissue injury, contamination, perforation, and worsening complications.

Place the patient in high-Fowler’s.

🔷High-Fowler’s increases tension on the abdominal incision.

🔷This can worsen evisceration and increase protrusion of abdominal contents.

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Answer 6

Correct Answers:

Stop suctioning, oxygenate the patient, and reassess

Rationale :

🔵 Stop suctioning immediately because a falling oxygen saturation indicates the patient is developing oxygen desaturation during the procedure.

🔵 Suctioning removes secretions but also temporarily removes oxygen from the airway, which can worsen hypoxia if continued.

🔵 After three passes, the nurse should provide supplemental oxygen and allow the patient time to recover.

🔵 Reassessment is needed to determine whether the patient’s oxygen saturation improves and whether further suctioning is still safe.

🔵 Patient safety takes priority over completely clearing secretions when signs of hypoxia appear.

Perform two more suction passes

🔵This can worsen oxygen desaturation because the patient is already showing signs of poor oxygenation.

🔵Additional passes should not be done until the patient is reoxygenated and reassessed.

Continue suctioning until the airway clears

🔵Continuous suctioning increases the risk of hypoxia, airway trauma, and cardiac dysrhythmias.

🔵Suctioning should be brief and interrupted when oxygen saturation drops.

Increase suction pressure and continue

🔵Higher suction pressure can damage airway mucosa and does not correct oxygen desaturation.

🔵The priority is oxygenation, not stronger suction pressure.

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Answer 7

Correct Answers:

Hematoma

Rationale :

🟣 A hematoma is a localized collection of blood under intact skin or within soft tissue.

🟣 It commonly occurs after trauma, such as a fall, when small blood vessels rupture beneath the skin.

🟣 The hip is a common site for hematoma formation after impact because soft tissue can collect pooled blood.

🟣 The skin remains intact, but the area may appear swollen, bruised, tender, or discolored.

🟣 Documenting the finding as a hematoma accurately describes pooled blood beneath the skin.

Abrasion.

🟣An abrasion is a superficial scraping or rubbing away of the skin surface.

🟣 It involves broken skin, not pooled blood under intact skin.

Avulsion.

🟣An avulsion is tearing away of tissue, often leaving a flap or missing skin.

🟣This does not describe intact skin with blood collected underneath.

Laceration.

🟣A laceration is a cut or tear in the skin or tissue.

🟣The question describes intact skin, so this term does not fit.

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Answer 8

Correct Answers:

A 90-year-old with CHF who has 3+ pitting edema in lower extremities

Rationale :

🟢 This patient has the highest risk because advanced age, CHF, and 3+ pitting edema all decrease tissue tolerance.

🟢 Edema stretches the skin and reduces oxygen and nutrient delivery to tissues, making skin more vulnerable to breakdown.

🟢 CHF can impair circulation, which slows healing and increases the risk of pressure injury formation.

🟢 A 90-year-old patient also has thinner skin, reduced subcutaneous tissue, and decreased ability to tolerate prolonged pressure.

🟢 The combination of poor circulation, edema, and advanced age places this patient at greatest risk.

An ambulatory 88-year-old with dementia who is admitted with shingles.

🟢 Dementia and age increase risk, but ambulation reduces prolonged pressure exposure.

🟢 Shingles affects skin integrity, but this patient is not described as immobile or edematous.

A 6-month-old with gastroenteritis who vomits and has diarrhea.

🟢Moisture and dehydration can increase skin risk, especially in the diaper area.

🟢 However, this risk is lower than severe edema with impaired circulation in an older adult.

A 71-year-old with a colostomy and feeding tube who goes to physical therapy daily.

🟢 A feeding tube and colostomy may indicate nutritional and skin-care needs.

🟢 Daily physical therapy suggests mobility, which lowers pressure ulcer risk.

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Answer 9

Correct Answers:

Restlessness

Rationale :

🟠 Restlessness is an early sign of hypoxia because the brain is very sensitive to reduced oxygen levels.

🟠 When oxygen delivery decreases, the patient may first show anxiety, agitation, confusion, or inability to remain calm.

🟠 Early recognition is important because hypoxia can progress quickly if not corrected.

🟠 The nurse should assess respiratory status, oxygen saturation, lung sounds, and airway patency.

🟠 Restlessness should never be ignored in a patient at risk for oxygenation problems.

Cyanosis.

🟠 Cyanosis is a late sign of hypoxia and indicates significant oxygen deprivation.

🟠 Waiting for cyanosis can delay urgent intervention.

Delirium.

🟠Delirium can occur with worsening hypoxia, especially in older adults.

🟠 It is not usually the earliest finding compared with restlessness.

Bradycardia.

🟠Bradycardia is generally a late and serious sign of hypoxia.

🟠 Early hypoxia more commonly causes tachycardia, restlessness, and anxiety.

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Answer 10

Correct Answers:

Visualization of the suture line separating

Rationale :

🔴 Wound dehiscence is the partial or complete separation of the wound edges after surgery.

🔴 Seeing the suture line separating is a direct sign that the incision is opening.

🔴 This is a serious postoperative complication because it can progress to evisceration if abdominal contents protrude.

🔴 The nurse should protect the wound, reduce strain on the incision, and notify the provider promptly.

🔴Early recognition prevents further tissue damage, infection, and emergency complications.

Increased pallor at the surgical site.

🔴Pallor may suggest reduced blood flow or poor perfusion.

🔴 It does not directly indicate that the wound edges are separating.

Excessive gas with abdominal pain.

🔴Gas and abdominal discomfort may occur after abdominal surgery due to slowed bowel activity.

🔴These findings do not define wound dehiscence.

Complaint of constipation.

🔴Constipation can increase abdominal pressure and strain the incision.

🔴However, it is not the finding that confirms dehiscence.

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QLexNursing

1 :
The nurse teaches a caregiver about preventing pressure ulcers. How does the nurse explain their cause?

2 :
The nurse is assessing a patient's wound. Based on the provided illustration, the nurse identifies the wound as which type of pressure injury?

3 :
A patient receives total parenteral nutrition (TPN). What is the correct rule for hanging a new TPN bag?

4 :
The nurse cares for a patient with a Jackson-Pratt (JP) drain. The nurse notes decreased drainage. What action does the nurse take?

5 :
A patient experiences evisceration of an abdominal wound. Which actions does the nurse take immediately? Select all that apply.

6 :
The nurse suctions a patient's airway and completes three passes. Secretions remain, and the patient's oxygen saturation begins to decrease. What action does the nurse take next?

7 :
A patient has pooled blood under intact skin of the hip after a fall. Which term does the nurse use to document this finding?

8 :
The nurse cares for four patients. Which patient has the highest risk for pressure ulcers?

9 :
The nurse monitors a patient for hypoxia. Which finding indicates early hypoxia?

10 :
The nurse monitors a patient after abdominal surgery. Which finding indicates wound dehiscence?

QLexNursing

1 : The nurse teaches a caregiver about preventing pressure ulcers. How does the nurse explain their cause?

2 : The nurse is assessing a patient's wound. Based on the provided illustration, the nurse identifies the wound as which type of pressure injury?

3 : A patient receives total parenteral nutrition (TPN). What is the correct rule for hanging a new TPN bag?

4 : The nurse cares for a patient with a Jackson-Pratt (JP) drain. The nurse notes decreased drainage. What action does the nurse take?

5 : A patient experiences evisceration of an abdominal wound. Which actions does the nurse take immediately? Select all that apply.

6 : The nurse suctions a patient's airway and completes three passes. Secretions remain, and the patient's oxygen saturation begins to decrease. What action does the nurse take next?

7 : A patient has pooled blood under intact skin of the hip after a fall. Which term does the nurse use to document this finding?

8 : The nurse cares for four patients. Which patient has the highest risk for pressure ulcers?

9 : The nurse monitors a patient for hypoxia. Which finding indicates early hypoxia?

10 : The nurse monitors a patient after abdominal surgery. Which finding indicates wound dehiscence?

1 :
The nurse teaches a caregiver about preventing pressure ulcers. How does the nurse explain their cause?

2 :
The nurse is assessing a patient's wound. Based on the provided illustration, the nurse identifies the wound as which type of pressure injury?

3 :
A patient receives total parenteral nutrition (TPN). What is the correct rule for hanging a new TPN bag?

4 :
The nurse cares for a patient with a Jackson-Pratt (JP) drain. The nurse notes decreased drainage. What action does the nurse take?

5 :
A patient experiences evisceration of an abdominal wound. Which actions does the nurse take immediately? Select all that apply.

6 :
The nurse suctions a patient's airway and completes three passes. Secretions remain, and the patient's oxygen saturation begins to decrease. What action does the nurse take next?

7 :
A patient has pooled blood under intact skin of the hip after a fall. Which term does the nurse use to document this finding?

8 :
The nurse cares for four patients. Which patient has the highest risk for pressure ulcers?

9 :
The nurse monitors a patient for hypoxia. Which finding indicates early hypoxia?

10 :
The nurse monitors a patient after abdominal surgery. Which finding indicates wound dehiscence?