Risk & Assessment
A nurse admits a bedridden client and must screen for pressure injury risk. Which tool, or the facility's preferred equivalent, identifies that risk?
What is the Braden Scale?
A nurse correctly positions a client on their side. The body is tilted to this angle range to reduce pressure on bony prominences.
What is 20° to 30°?
A nurse bathes a client with fragile skin. Which force from vigorous rubbing should be avoided to prevent damage?
What is friction?
A clean laceration is closed with sutures and heals quickly. Which healing type, also called first intention, is this?
What is primary healing? (also called first intention)
A client on anticoagulants has a swollen collection of blood under the skin after a clot fails to form. What is it?
What is a hematoma?
A client is admitted to the unit. Within how many hours must the nurse document a skin assessment?
What is 24 hours?
A client keeps sliding down in bed and has sacral pressure. The nurse lowers the head of the bed. Below what angle should it stay?
What is 30°?
A client's dry skin is irritated by traditional cleansers. Which type of cleanser should the nurse choose instead?
What are pH-balanced foam cleansers?
A wound is left open, and granulation tissue fills it from the bottom up. Which type of healing is this?
What is secondary healing (second intention)?
A nurse prepares to collect a wound culture. Which solution should be used to clean the wound first?
What is 0.9% sodium chloride (normal saline)?
Sadly, the nurse discovers a toddler has lain in one position for hours. Which part of the head should the nurse also check for pressure injury?
What is the occiput?
A client at high risk for pressure injury is placed on a surface that redistributes pressure through a dynamic system. What type of surface is this?
What are supportive surfaces?
A client has dry, fragile skin and is at risk for skin tears. Which moisturizing products promote skin health and reduce that risk?
What are emollients?
A wound is left open for 5 to 10 days before suturing. Which healing method, also called tertiary intention, is used?
What is delayed primary closure?
On day 6 after abdominal surgery, a client has a sudden gush of pink, watery drainage from the incision.
What is dehiscence?
A new admission has been checked by only one nurse. But how many RNs should actually assess the skin on admission so findings can be confirmed?
What is two?
A client was on bed rest but began sitting and walking as soon as they could tolerate being OOB. What is this process called?
What is early mobilization?
A malnourished client has a slow-healing wound. Which two vitamins are essential for wound healing and tissue strengthening?
What are vitamins A and C?
In the first 3 to 6 days after injury, bleeding stops and white blood cells flood the wound. Which phase is this?
What is the hemostatic/inflammatory phase?
A surgical site infection develops after surgery. Which bacterium, found in the nose and on the skin, is the most common cause?
What is Staphylococcus aureus?
A client with incontinence has skin that is broken down and fragile from prolonged moisture exposure. Which term describes this finding on head-to-toe assessment?
What is maceration?
A client in pain must be repositioned to prevent pressure injury. Which medication should the nurse consider giving first?
What is analgesia?
A client has lost weight without trying. Which finding should the nurse flag as a risk for malnutrition?
What is unintentional weight loss?
Starting around day 21 and lasting over a year, the wound replaces collagen with stronger collagen. Which phase is this
What is the remodeling (maturation) phase?
A client's abdominal incision has opened, and intra-abdominal organs protrude through the suture line. What is the priority action?
What is cover with saline-soaked sterile dressing and call for help?