Pressure Injuries (15 Questions)

1. A 78‑year‑old client with limited mobility has a reddened area over the sacrum. The skin is intact, non‑blanchable, warm to touch, and firmer than surrounding tissue.

Question:
Which stage of pressure ulcer should the nurse suspect? *
2. Mr. Dubois suffered a left-sided cerebrovascular accident three days ago and remains bedbound with right-sided weakness. He is alert but has difficulty communicating his needs. During a routine skin assessment, the nurse observes an intact, fluid-filled blister over the right heel. The blister measures approximately 1.5 cm in diameter, is clear and serous, not bloody or purulent. The surrounding skin is pink and warm, with no slough or open wound. The area is tender to light touch. The patient cannot reposition his right leg independently.

Question:
Based on this assessment, which stage of pressure injury should the nurse document? *
3. The nurse assesses a client’s heel and notes a purple‑maroon area of intact skin that is boggy and painful to touch. There is no open break in the skin.

Question:
What should the nurse suspect is happening? *
4. Ms. Claire Bérubé, 85 years old, is hospitalized on a medical unit for acute exacerbation of heart failure and pneumonia. She is weak, requires two-person assistance for transfers, and spends most of the day in bed. She is receiving IV antibiotics and has developed frequent loose stools (4–6 episodes/day). She is also urinary incontinent and wears briefs. She reports burning discomfort around the buttocks and perineum.

On day 3, during hygiene care, the nurse notes the following:
*Diffuse erythema to the perineum and gluteal cleft
*Whitened, soggy (“waterlogged”) skin with superficial peeling at the gluteal cleft
*Irregular borders, not centered over a bony prominence
8No crater, no slough, no eschar, and no visible subcutaneous tissue
*The area is moist, and there is stool residue noted in skin folds

The nurse reviews Ms. Bérubé’s Therapeutic Nursing Plan (TNP). Current directives include:
*Reposition every 2 hours and use a pressure-redistributing mattress.
*Offload heels with heel protectors.
*Encourage protein intake; dietitian consult in place.
*Document skin assessment once per shift.

Despite these measures, the skin findings are worsening and are consistent with maceration due to moisture exposure (incontinence-associated skin damage).

Question:
To prevent progression of maceration, which new directive should the nurse add to the Therapeutic Nursing Plan? *
5. Mr. Jean Gagnon, age 83, is admitted to a medical unit for pneumonia. He is drowsy after receiving opioid analgesia for chest pain, responds slowly, and cannot reposition himself in bed. His hospital gown is damp due to episodes of urinary incontinence. On assessment, the sacral skin is intact and slightly pink with no open area. You complete the Braden Scale: Sensory perception 2, Moisture 2, Activity 1, Mobility 1, Nutrition 2, Friction/Shear 2.

Question:
Which nursing intervention should be implemented first? *
6. Ms. Sophie Tremblay, age 79, is admitted to surgery after a hip fracture. She walks very little, sits briefly in a chair with assistance, has had poor intake for weeks, and has episodes of diarrhea. Her admission Braden score is 12.

Question:
How should the nurse interpret this result? *
7. Mr. Philippe Morin, age 71, is bedbound after a recent stroke and requires total assistance with hygiene and transfers. During repositioning, you observe on the right greater trochanter a partial-thickness skin loss: a small, superficial open area with a moist pink-red wound bed, no visible slough, resembling a ruptured blister. He reports mild pain at the site.

Question:
Which pressure injury stage should the nurse suspect? *
8. Mr. Charles Nguyen, age 75, lives in a long-term care facility. He has a confirmed stage 2 sacral pressure injury: small, superficial, low exudate, clean moist pink-red wound bed, no odor. He is urinary incontinent overnight.

Question:
Which dressing is most appropriate to promote healing and protect the wound? *
9. Ms. Louise Bouchard, age 82, has diabetes and very limited mobility. She has a stage 3 sacral pressure injury: full-thickness skin loss with visible subcutaneous tissue, moderate serous drainage, minimal slough, no exposed bone or tendon.

Question:
Which dressing is most appropriate to manage drainage while maintaining a moist wound environment? *
10. Mr. Antoine Leblanc, age 74, has respiratory insufficiency and the head of his bed is often kept at 60 degrees. You notice he frequently slides down in bed despite repositioning. Persistent redness develops at the coccyx, followed by a small superficial open area.

Question:
Which factor most contributes to his injury? *
11. Ms. Hélène Roy, age 86, is bedbound and has urinary and fecal incontinence. You observe diffuse redness and superficial maceration in the perineal area and gluteal cleft, with irregular edges and not centered over a bony prominence.

Question:
Which nursing measure is most appropriate to prevent worsening? *
12. Mr. Robert Côté, age 80, has peripheral arterial disease and is hospitalized for heart failure. On the right heel you see a dry, hard, black eschar that is firmly adherent, with no surrounding redness, drainage, odor, or fever.

Question:
What is the most appropriate nursing action? *
13. Ms. Carole Sarrasin, age 77, has a stage 4 sacral pressure injury followed for several weeks. Over the last 48 hours she developed a fever (38.5°C), increased wound pain, foul odor, and purulent drainage, with marked fatigue.

Question:
Which complication should the nurse suspect and report promptly? *
14. Ms. Denise Carter, 71, is post-stroke with poor trunk control. The nurse observes that she frequently slides down in bed, and she now has a pressure injury developing over the coccyx.

Question:
Which nursing intervention best addresses the primary mechanism contributing to her skin injury? *
15. Mr. Walter Singh, 79, lives in a long-term care facility. Despite a turning schedule, he developed a stage 3 pressure injury on the greater trochanter. He is underweight, eats poorly, and has low serum albumin.

Question:
Which factor most likely contributed to the development and poor healing of his pressure injury? *