Pressure Injury Practice Questions with Answers and NCLEX® Review

Pressure injuries, also known as pressure ulcers, bedsores, or decubitus ulcers, are localized injuries to the skin and/or underlying tissue, usually over a bony prominence, as a result of prolonged pressure or friction. 

Pressure Injury Practice Questions with Answers and Practice Questions

{{question_current_index+1}}/{{question_max_index+1}} QUESTIONS

TEST YOUR KNOWLEDGE
{{question_current_index+1}}/{{question_max_index+1}} QUESTIONS

play-sharp-fill

Overview

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec non tellus ut sem commodo blandit. Suspendisse nisi orci, pellentesque faucibus dolor ut, aliquam iaculis est.

Learning Outcomes

Sed at turpis sit amet urna malesuada fermentum. Nulla convallis vehicula lobortis. Quisque dictum mauris sed tincidunt congue. Duis finibus turpis massa, sit amet porttitor est dignissim vel. Integer rhoncus sollicitudin ligula, ut feugiat dolor interdum at. Nulla sit amet odio a erat ultricies vestibulum. Aliquam erat volutpat. Curabitur tristique metus sed dapibus fringilla. Sed hendrerit viverra leo, ut consectetur metus mollis vel. Morbi ultricies nibh eu bibendum dignissim.
Other
Students
0%
answered correctly
0%
answered wrongly

Rationales

0% answered this

Test Taking Tips

Table of contents

    Introduction to Pressure Injuries

    There are six stages of pressure injuries based on the extent of tissue damage, ranging from Stage 1 to Stage 4, as well as two additional stages, suspected deep tissue injury and unstageable, which can occur.

    It is essential to assess pressure injuries on admission to a facility and daily to determine their stage and to initiate appropriate interventions to promote healing and prevent further damage.

    Pressure Injury Pathophysiology

    Ischemia and tissue necrosis as a result of sustained pressure over a prolonged period of time results in damage to the skin and/or the underlying tissue over a bony prominence. This is most

    common with immobile clients who have not turned adequately or who have a medical device that causes irritation such as oxygen tubing.

    Most common areas include:

    •  lower back and buttocks (sacrum and coccyx)
    •  heels and ankles
    •  hip bones
    •  shoulder area and elbows

    Pressure Injury Causes and Risks

    • Immobility
    • Incontinence
    • Poor nutrition
    • Diabetic neuropathy
    • Liver cirrhosis = Low Albumin
    Are you
    preparing
    to take the
    NCLEX?

    Stages of Pressure Injuries

    Stage 1: One Layer of Damage (Epidermis)

    Epidermis injuries are the earliest and least severe stage of pressure injury. This stage is characterized by red skin that is non-blanchable and not broken over a bony prominence. 

    Stage 2: Two Layers of Damage

    This stage indicates an open wound, affecting both the epidermis and dermis. The wound bed is red or pink, and shiny or dry.

    The pressure injury is characterized by partial thickness skin loss that involves the epidermis and/or dermis. The wound bed is visible, and the area may appear as a blister or shallow crater.

    Stage 3: Three Layers of Damage (Epidermis, Dermis, and Subcutaneous)

    This stage is characterized by full-thickness skin loss into the subcutaneous fat. The wound may tunnel under the edges of the wound bed (appearing as a deep crater).

    The pressure injury is characterized by full-thickness skin loss that involves damage or necrosis of subcutaneous tissue, but not extending to the underlying fascia. 

    Stage 4: Four Layers of Damage

    This wound extends all the way down into muscle, bone, or tendon.

    The pressure injury is the most severe form of pressure injury. It’s characterized by full-thickness skin and tissue loss, extending through the fascia and often resulting in extensive tissue destruction, such as muscle, bone, and tendons.

    The Eschar Stage

    This is an area of intact skin with a dark, purple, or maroon discoloration or a blood-filled blister, which indicates damage to underlying soft tissue. The area may be painful, firm, mushy, or boggy to the touch. This stage is characterized by dead necrotic tissue, and may rapidly progress to deeper stages.

    Deep Tissue Injury (DTI)

    The fatty tissue is injured below the skin (dark purple, and sometimes open wound) at this point. 

    An unstageable pressure injury is covered by eschar or slough, which makes it difficult to determine the extent of tissue damage. The area may be black, brown, or yellow.

    Pressure Injury Treatment & Nursing Interventions

    • Assess skin and document on admission and every shift or daily.
    • Keep the client clean and dry with less layers under them.
    • Turn the client every two hours.
    • Provide special mattresses to relieve pressure.
    • Nutrition: Protein and Fluids (2 – 3 L / day)
      • Urine output 30 mL/hr or Less = Kidney Distress
    • Monitor for:
      • Stage, size, and color
    Photo of Amy Stricklen
    Amy Stricklen
    “

    During my exam, I could literally see and hear him going over different areas as I was answering my questions.

    This past Friday I retook my Maternity Hesi and this time, I decided for my last week of Holiday break to just watch all of his OB videos. I am proud to say that with Mike’s help I received a score of 928 on my Maternity Hesi!

    Photo of Amy Stricklen
    Amy Stricklen

    Need help with your next exam? Our proven system has helped over 1,000,000 nursing students reduce their study time, survive their nursing school lectures and PASS their exams! SimpleNursing membership offers:

    • 1,100 fun and visual videos covering the most highly tested topics in RN/PN nursing programs
    • 900+ pages of cheat sheets & done-for-you study guides
    • Test tips and memory tricks included
    See how our members are
    earning a 96% pass rate.
    Get started now For Free