Wound Care Certification Pressure Injury Prevention Questions and Answers — Questions and Answers
Question 1: A nurse is completing a risk assessment for pressure injury using the Braden Scale on a new resident in a long-term care facility. The resident scores a 16. What is the appropriate interpretation of this score?
- The resident is at high risk.
- The resident is at moderate risk.
- The resident is at mild risk. (Correct answer)
- The resident has no risk.
Correct answer: The resident is at mild risk.
According to the Braden Scale for Predicting Pressure Sore Risk, a total score of 15-18 is categorized as mild risk. A score of 13-14 is moderate risk, 10-12 is high risk, and 9 or less is severe risk.
Question 2: A 78-year-old male is admitted to the hospital with pneumonia and is largely immobile. Which of the following is the MOST critical initial step in a pressure injury prevention plan?
- Ordering a specialized low-air-loss mattress.
- Conducting a comprehensive skin assessment and risk evaluation. (Correct answer)
- Establishing a 2-hour turning and repositioning schedule.
- Requesting a dietary consult for high-protein supplements.
Correct answer: Conducting a comprehensive skin assessment and risk evaluation.
The foundational step in any pressure injury prevention plan is to first assess the patient's individual risk and inspect their skin. This comprehensive assessment guides all subsequent interventions, such as selecting an appropriate support surface, determining repositioning frequency, and implementing nutritional support.
Question 3: Which of the following nutritional recommendations is MOST important for an individual at high risk for pressure injury development?
- A high-carbohydrate, low-fat diet.
- Increased fluid intake and adequate protein. (Correct answer)
- Supplementation with vitamin K.
- A calorie-restricted diet to manage weight.
Correct answer: Increased fluid intake and adequate protein.
Adequate hydration is crucial for maintaining skin turgor and perfusion, while sufficient protein is essential for tissue repair and maintenance. International guidelines emphasize ensuring adequate intake of fluid and protein as key nutritional interventions for pressure injury prevention.
Question 4: When repositioning a patient to prevent pressure injuries on the sacrum, what is the recommended side-lying position?
- A 90-degree lateral position.
- A 30-degree lateral inclined position. (Correct answer)
- The prone position.
- A high-Fowler's position.
Correct answer: A 30-degree lateral inclined position.
The 30-degree lateral inclined position is recommended to relieve pressure from the sacrum and coccyx without placing the full weight on the trochanter, which can happen in a 90-degree position. This position effectively offloads common pressure points.
Question 5: A clinician is caring for a patient who is chair-bound for most of the day. According to the 2019 International Clinical Practice Guideline, which intervention is a priority for this patient?
- Repositioning the patient in the chair every 4 hours.
- Using a donut-shaped cushion for pressure relief.
- Ensuring the patient's heels are elevated off the footrests.
- Using a pressure-redistributing chair cushion and regular repositioning. (Correct answer)
Correct answer: Using a pressure-redistributing chair cushion and regular repositioning.
For individuals who are chair-bound, it is critical to use a pressure-redistributing cushion to manage pressure on the ischial tuberosities. Additionally, these individuals should be repositioned regularly. The guideline does not recommend donut-type devices as they can cause circumferential pressure and impede circulation.
Question 6: All of the following are functions of a pressure-redistributing support surface EXCEPT:
- Controlling the microclimate of the skin.
- Eliminating the need for patient repositioning. (Correct answer)
- Reducing shear and friction forces.
- Immersing and enveloping the body to redistribute pressure.
Correct answer: Eliminating the need for patient repositioning.
While specialized support surfaces are a key component of pressure injury prevention, they do not eliminate the need for regular repositioning. Turning and repositioning remain a crucial intervention to alter the location, duration, and magnitude of pressure on vulnerable tissues, even when a therapeutic surface is in use.
Wound Care Certification Pressure Injury Prevention Questions and Answers
A nurse is completing a risk assessment for pressure injury using the Braden Scale on a new resident in a long-term care facility.
The resident scores a 16.
What is the appropriate interpretation of this score?