A nurse is caring for a bedridden elderly patient who has limited mobility. The nurse notices redness on the patient’s sacral area. What is the priority nursing action?
A) Apply a cold compress to the affected area.
B) Massage the area gently to improve blood circulation.
C) Reposition the patient every two hours.
D) Use a donut-shaped cushion for support.
E) Administer an analgesic for pain relief.
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Rationale: The priority in preventing pressure ulcers is regular repositioning to relieve pressure on vulnerable areas. Repositioning every two hours helps distribute pressure evenly, reducing the risk of tissue damage. Cold compresses and massage may exacerbate skin damage, and donut-shaped cushions are not recommended due to potential pressure on the center. Analgesics address pain but do not address the root cause of pressure ulcers.
POP QUIZ
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A patient with diabetes mellitus is admitted to the hospital. The nurse identifies areas of skin breakdown on the patient’s heels. What intervention should the nurse prioritize?
A) Elevate the patient’s heels with pillows.
B) Apply a moisture-barrier cream to the affected areas.
C) Keep the patient’s heels uncovered.
D) Use a pressure-relieving heel boot.
E) Administer antibiotics prophylactically.
Rationale: Patients with diabetes are at increased risk of pressure ulcers, especially on the heels. A pressure-relieving heel boot helps distribute pressure, reducing the risk of further skin breakdown. Elevating the heels with pillows may compromise blood flow, and moisture-barrier creams alone may not address pressure. Keeping the heels uncovered exposes them to additional pressure, and prophylactic antibiotics are not indicated for pressure ulcers.
NCLEX Review: Pressure Ulcers Treatments
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A postoperative patient is immobile and has developed a pressure ulcer on the coccyx. The wound is clean, but there’s minimal improvement in healing. What intervention should the nurse prioritize?
A) Apply a hydrocolloid dressing to the ulcer.
B) Perform regular debridement of the wound.
C) Administer a high-dose antibiotic.
D) Increase the patient’s protein intake.
E) Use a heat lamp to promote healing.
Rationale: Regular debridement is essential for removing necrotic tissue and promoting wound healing. Hydrocolloid dressings create a moist environment but may not be suitable for all wounds. High-dose antibiotics are not indicated unless there’s infection. Increasing protein intake supports overall healing but may not address local wound issues. Heat lamps can increase the risk of further tissue damage and are not recommended for pressure ulcers.
Understanding Pressure Ulcers: NCLEX Priority Questions
A nurse is caring for an elderly patient who recently underwent surgery and is now bedridden. The nurse observes a reddened area on the patient’s hip. What is the initial nursing action?
A) Apply a warm compress to the affected area.
B) Document the finding in the patient’s chart.
C) Massage the reddened area to improve blood flow.
D) Reposition the patient to relieve pressure.
E) Administer an over-the-counter topical ointment.
Rationale: The initial action in preventing and managing pressure ulcers is to relieve pressure on vulnerable areas. Repositioning the patient helps redistribute pressure and promotes blood circulation. Warm compresses and massage may aggravate the condition, and documentation alone does not address the patient’s immediate needs. Over-the-counter ointments are not the primary intervention for preventing pressure ulcers.
NCLEX Questions Critical Thinking: Pressure Ulcers Symptoms
A nurse is caring for a critically ill patient in the intensive care unit. The patient is immobile and at high risk for pressure ulcers. What intervention should the nurse prioritize?
A) Apply a transparent film dressing to bony prominences.
B) Keep the patient’s linens dry and free of wrinkles.
C) Use a high-air-loss mattress for pressure redistribution.
D) Encourage the patient to perform range-of-motion exercises.
E) Apply a petroleum-based ointment to susceptible areas.
Rationale: Critically ill patients are at increased risk of pressure ulcers, and using a high-air-loss mattress is an effective strategy for pressure redistribution. Transparent film dressings may be suitable for specific wounds but do not address overall pressure management. Keeping linens dry and smooth is important but does not directly prevent pressure ulcers. Range-of-motion exercises are beneficial but may not be feasible for critically ill patients. Petroleum-based ointments are not the primary intervention for preventing pressure ulcers.
Understanding the Pressure Ulcers: NCLEX Delegation Questions
A patient with limited mobility due to a neurological disorder has developed a stage II pressure ulcer on the sacral area. What intervention is most appropriate for promoting wound healing?
A) Apply a hydrogel dressing to the ulcer.
B) Administer a broad-spectrum antibiotic.
C) Use a wound vacuum-assisted closure device.
D) Keep the ulcer exposed to air for optimal healing.
E) Encourage the patient to increase fluid intake.
Rationale: Hydrogel dressings provide a moist environment, promoting wound healing for stage II pressure ulcers. Broad-spectrum antibiotics are not indicated unless there is an infection. Wound vacuum-assisted closure devices are more appropriate for advanced wounds. Keeping the ulcer exposed to air is not recommended, as a moist environment supports healing. While hydration is essential, it may not directly impact wound healing in this context.
Understanding Pressure Ulcers: NCLEX Delegation Questions
A nurse is caring for an elderly patient who has been bedridden for an extended period. The nurse notices a deep, open wound on the patient’s sacral area. What is the immediate nursing action?
A) Clean the wound with hydrogen peroxide.
B) Apply a sterile dressing to the wound.
C) Document the wound appearance and size.
D) Administer an oral antibiotic.
E) Reposition the patient to relieve pressure.
Rationale: The immediate priority for an open pressure ulcer is to relieve pressure on the affected area to prevent further damage. Cleaning the wound, applying a dressing, and documenting are important but secondary actions. Administering an oral antibiotic is not the primary intervention for pressure ulcers unless there is evidence of infection.
Understanding the Pressure Ulcers: NCLEX Delegation Questions
A postoperative patient is at risk for pressure ulcers due to immobility. The nurse observes redness on the patient’s heels. What intervention should the nurse implement?
A) Apply a heating pad to improve circulation.
B) Use a donut-shaped cushion for support.
C) Elevate the patient’s heels with pillows.
D) Apply a silicone-based dressing to the heels.
E) Implement regular heel offloading techniques.
Rationale: Regular offloading of pressure on vulnerable areas, such as the heels, is crucial in preventing pressure ulcers. Heating pads may increase the risk of tissue damage, and donut-shaped cushions are not recommended. Elevating the heels with pillows may compromise blood flow. Silicone-based dressings may have specific indications but are not the primary intervention for preventing pressure ulcers.
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NCLEX Practice Questions: Understanding Pressure Ulcers Causes and Symptoms
A patient with a spinal cord injury is susceptible to pressure ulcers. The nurse notes an area of intact skin but with non-blanchable erythema. What action should the nurse take?
A) Apply a cold compress to reduce redness.
B) Massage the area gently to promote circulation.
C) Document the finding and continue monitoring.
D) Initiate wound debridement.
E) Apply a topical steroid ointment.
Rationale: Non-blanchable erythema indicates early-stage pressure injury. The appropriate action is to document the finding, continue monitoring, and implement preventive measures. Applying a cold compress and massage may exacerbate skin damage. Wound debridement is not indicated at this stage, and topical steroid ointments are not the primary intervention for preventing pressure ulcers.
NCLEX Questions: Focus on Medications for Pressure Ulcers
A bedridden patient has a stage III pressure ulcer on the buttocks. The wound is clean with no signs of infection. What dressing is most appropriate for this wound?
A) Alginate dressing
B) Transparent film dressing
C) Hydrocolloid dressing
D) Dry sterile gauze dressing
E) Foam dressing
Rationale: Hydrocolloid dressings create a moist environment, promoting healing in stage III pressure ulcers. Alginate dressings are more suitable for wounds with exudate. Transparent film dressings may not provide the necessary moisture for this wound type. Dry sterile gauze dressing may adhere to the wound bed, causing trauma during dressing changes. Foam dressings are often used for wounds with moderate to heavy exudate and may not be ideal for a clean stage III pressure ulcer.
