Pressure Injury Prevention, Assessment, and Staging

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1. 1

   A shallow wound has exposed, moist, pink dermis without slough, granulation tissue, or visible fat. What is its stage?

   

   A Stage 1 pressure injury B Stage 2 pressure injury C Stage 3 pressure injury
2. 2

   The base of a full-thickness wound is completely covered by slough and eschar, preventing assessment of its depth. How should it be documented?

   A Stage 2 pressure injury B Deep tissue pressure injury C Unstageable pressure injury
3. 3

   The image shows intact heel skin with persistent maroon discoloration after prolonged pressure. Which classification is most appropriate?

   

   A Deep tissue pressure injury B Stage 1 pressure injury C Stage 3 pressure injury
4. 4

   The patient shown has repeatedly slid toward the foot of the elevated bed. Which force most directly distorts deeper tissues in this situation?

   

   A Moisture B Shear C Maceration
5. 5

   Which group contains only domains evaluated by the Braden Scale?

   A Pain, circulation, temperature B Oxygenation, cognition, medication use C Sensory perception, moisture, activity
6. 6

   What is the best approach to repositioning a patient at risk of pressure injury?

   A Use an individualized schedule based on risk, skin response, mobility, and support surface B Reposition every six hours regardless of clinical condition C Avoid repositioning whenever a pressure-redistributing mattress is used
7. 7

   Which positioning technique shown is appropriate for preventing heel pressure injuries?

   

   A Place a firm ring-shaped cushion directly under each heel B Support the calves so the heels float free of the mattress C Press the heels firmly into the mattress to prevent foot movement
8. 8

   A patient has frequent urinary and fecal incontinence. Which intervention best protects the skin from moisture-associated damage?

   A Scrub the skin vigorously after every episode B Apply talcum powder in thick layers to retain moisture C Cleanse gently, dry carefully, and apply an appropriate moisture barrier
9. 9

   A patient with a pressure injury has recent unintentional weight loss and poor food intake. What is the most appropriate response?

   A Perform nutrition screening and arrange a comprehensive assessment with an individualized plan B Restrict protein to reduce wound drainage C Use supplements as a permanent substitute for all regular meals
10. 10

    The image shows dry, firmly adherent heel eschar without redness, drainage, fluctuance, or separation. What is generally the appropriate initial approach?

    

    A Soak and remove it immediately at the bedside B Leave it intact, offload the heel, and monitor closely C Massage the heel until the eschar loosens
11. 11

    Which group of findings is most concerning for local pressure injury infection?

    A Stable wound size, healthy granulation, decreasing pain B Dry intact skin, normal temperature, no drainage C Increasing pain, warmth, purulent drainage, and spreading redness
12. 12

    Which documentation is most useful when monitoring a pressure injury over time?

    A Location, stage, dimensions, tissue type, drainage, wound edges, and surrounding skin B Only the wound stage and dressing brand C Only whether the wound appears better or worse
13. 13

    What is the correct role of a pressure-redistributing support surface?

    A It eliminates the need for regular skin assessment B It reduces pressure exposure but does not replace repositioning and other prevention measures C It is needed only after a Stage 4 injury develops
14. 14

    How should a pressure injury located on a mucous membrane be classified?

    A Always as Stage 2 B According to the depth of visible tissue loss C Documented as a mucosal pressure injury without assigning a numerical stage
15. 15

    The image shows a localized injury behind the ear that matches the shape of oxygen tubing. Which principle applies?

    

    A It is a medical device-related pressure injury and should be staged when it affects skin B It cannot be a pressure injury because it is not over a bony prominence C It should be classified only as an allergic reaction
16. 16

    A red area over the sacrum turns pale when gently pressed and then quickly returns to its original color. What does this indicate?

    A Confirmed Stage 2 pressure injury B Confirmed deep tissue pressure injury C Blanchable erythema rather than the defining non-blanchable finding of Stage 1
17. 17

    The wound cross-section shows tissue destruction extending sideways beneath an intact wound edge. What is this finding called?

    

    A Undermining B Maceration C Epithelialization
18. 18

    A patient with a pressure injury develops fever, new confusion, rapid breathing, and low blood pressure. What is the priority action?

    A Wait until the next routine wound review B Initiate urgent medical evaluation for possible systemic infection or sepsis C Apply a thicker dressing and reassess in several days