Wound Care and Pressure Injury Staging Flashcards

Which Braden Scale subscale specifically evaluates the patient's ability to change and control body position?

Answer: Mobility

The Mobility subscale assesses the patient's ability to change and control body position independently.

A patient has a stage 3 pressure injury on the heel. What is the recommended approach for heel pressure injuries with stable eschar?

Answer: Leave stable, dry eschar on heel intact as a natural cover

Stable, dry eschar on the heel serves as a biological cover and should not be debrided unless signs of infection develop.

Which lab value is MOST useful for evaluating a patient's nutritional status in relation to wound healing?

Answer: Serum albumin

Serum albumin reflects protein stores and is commonly used to assess nutritional status related to wound healing, although it has limitations.

A patient develops a pressure injury over the ischial tuberosity. Which position places the GREATEST pressure on this site?

Answer: Sitting

The sitting position places the highest pressure over the ischial tuberosities, making this site particularly vulnerable in wheelchair-bound patients.

When applying a hydrocolloid dressing to a stage 2 pressure injury, the LPN should:

Answer: Leave 2–3 cm of dressing border beyond the wound edge

Hydrocolloid dressings should extend 2–3 cm beyond the wound edge to ensure proper adhesion and protection.

A postoperative patient has redness, warmth, purulent drainage, and an odor from a surgical incision. These findings are MOST consistent with:

Answer: Wound infection

Purulent drainage, odor, erythema, and warmth are classic signs of wound infection requiring prompt reporting and intervention.

What is the PRIMARY goal of negative pressure wound therapy (NPWT/VAC)?

Answer: Promote granulation tissue formation and reduce edema

NPWT promotes granulation tissue formation, reduces wound edema, and removes excess exudate to accelerate wound healing.