CNA Skin Care and Pressure Injury Prevention 2 — Questions and Answers
Question 1: A pressure injury presents as intact skin with non-blanchable localized redness over a bony prominence. How is it classified?
- Stage 1 (Correct answer)
- Stage 2
- Deep tissue pressure injury
- Unstageable
Correct answer: Stage 1
Stage 1 is defined by intact skin with non-blanchable redness, representing the earliest sign of pressure damage without open skin.
Question 2: Which resident is at the HIGHEST combined risk for developing a pressure injury?
- A bedridden resident with poor nutrition and incontinence (Correct answer)
- A mobile resident with mild hypertension
- A resident who uses a walker and has a good appetite
- An overweight resident who is ambulatory
Correct answer: A bedridden resident with poor nutrition and incontinence
Immobility, poor nutrition, and incontinence are three of the strongest independent risk factors that together create very high pressure injury risk.
Question 3: During bathing, which observation should a CNA prioritize reporting to the nurse?
- Redness, open areas, or bruising over bony prominences (Correct answer)
- Skin that appears its normal color throughout
- Skin that is warm and intact in all areas
- Skin that is moist immediately after rinsing
Correct answer: Redness, open areas, or bruising over bony prominences
Redness, open areas, or bruising over bony prominences are early warning signs of pressure injury that require prompt nursing assessment.
Question 4: What is the FIRST action a CNA should take after noticing a new reddened area on a resident's sacrum?
- Apply lotion to the area and continue care as planned
- Report the finding to the nurse immediately and document it (Correct answer)
- Scrub the area to improve circulation
- Move the resident to a pressure-relief mattress without notifying staff
Correct answer: Report the finding to the nurse immediately and document it
Any new skin change must be reported to the nurse immediately because early intervention is critical to preventing a Stage 1 finding from progressing.
Question 5: Shear injury to the skin occurs when:
- Skin is rubbed back and forth against bed sheets during repositioning
- The skin moves in one direction while the underlying tissues move in the opposite direction (Correct answer)
- The skin remains in prolonged contact with moisture
- Direct downward pressure is applied to a bony prominence
Correct answer: The skin moves in one direction while the underlying tissues move in the opposite direction
Shear stress damages blood vessels and deep tissues when the skin surface and the tissue beneath it slide in opposite directions, as when a resident slides down in bed.
Question 6: The Braden Scale is a clinical tool used to:
- Determine the stage of an existing pressure injury
- Measure the dimensions of a wound
- Assess a resident's risk level for developing pressure injuries (Correct answer)
- Document the amount and type of wound drainage
Correct answer: Assess a resident's risk level for developing pressure injuries
The Braden Scale scores six risk factors — sensory perception, moisture, activity, mobility, nutrition, and friction/shear — to predict pressure injury risk.
Question 7: Which action should a CNA AVOID when caring for a resident at risk for pressure injuries?
- Keeping the resident's skin clean and dry after incontinence
- Using a draw sheet to reposition the resident up in bed
- Massaging reddened areas over bony prominences (Correct answer)
- Elevating the resident's heels off the mattress with pillows
Correct answer: Massaging reddened areas over bony prominences
Massaging reddened bony prominences can further damage already compromised capillaries and worsen tissue injury rather than improve circulation.
CNA Skin Care and Pressure Injury Prevention 2
A pressure injury presents as intact skin with non-blanchable localized redness over a bony prominence.
How is it classified?