UNAR Skin Care and Pressure Injury Prevention 2 — Questions and Answers
Question 1: Which nursing assistant action best prevents skin breakdown in a bedridden patient?
- Keeping the patient in one comfortable position throughout the shift
- Regular repositioning combined with keeping skin clean and dry (Correct answer)
- Applying lotion to all areas of redness immediately
- Massaging bony prominences vigorously to increase circulation
Correct answer: Regular repositioning combined with keeping skin clean and dry
Regular repositioning relieves sustained pressure while keeping skin clean and dry addresses moisture — together these two interventions target the main causes of skin breakdown.
Question 2: What should a nursing assistant do upon finding an area of redness on a patient's skin that does not blanch (turn white) when pressed?
- Apply a warm compress to the area and continue routine care
- Massage the reddened area vigorously to improve circulation
- Report it immediately to the nurse (Correct answer)
- Cover it with an adhesive bandage and monitor it independently
Correct answer: Report it immediately to the nurse
Non-blanchable redness is a sign of a Stage 1 pressure injury indicating compromised blood flow, and must be reported immediately to the nurse for professional assessment and care planning.
Question 3: Which patient condition significantly increases the risk of developing pressure injuries?
- Regular ambulation three times per day
- Good nutritional status with high protein intake
- Urinary or bowel incontinence (Correct answer)
- Adequate daily hydration of 2 liters
Correct answer: Urinary or bowel incontinence
Incontinence continuously exposes the skin to moisture, urine, and stool — chemical irritants that weaken the skin's protective barrier and dramatically increase the risk of skin breakdown.
Question 4: What is the main purpose of using a draw sheet when repositioning a patient in bed?
- To keep the patient warm during position changes
- To reduce friction and shear forces on the patient's skin during movement (Correct answer)
- To protect the mattress from becoming soiled
- To secure the patient safely during transport between rooms
Correct answer: To reduce friction and shear forces on the patient's skin during movement
A draw sheet allows caregivers to slide the patient rather than drag them, significantly reducing friction and shear forces on the skin that can cause tissue damage.
Question 5: How should a nursing assistant properly dry a patient's skin after bathing?
- Scrub vigorously with a terry cloth to remove dead skin cells
- Use hot water rinse to open pores before drying
- Pat skin dry gently, paying special attention to skin folds (Correct answer)
- Leave skin slightly damp to prevent excessive dryness
Correct answer: Pat skin dry gently, paying special attention to skin folds
Gently patting the skin dry, especially in folds (groin, under breasts, between toes), prevents moisture buildup that leads to maceration, fungal infections, and skin breakdown.
Question 6: What is 'shearing' in the context of skin and pressure injury care?
- The cutting or trimming of nails and cuticles during grooming
- Force applied directly perpendicular down onto a skin surface
- Opposing mechanical forces that stretch and damage skin layers in different directions (Correct answer)
- Friction created by rubbing two skin surfaces together repeatedly
Correct answer: Opposing mechanical forces that stretch and damage skin layers in different directions
Shearing occurs when skin layers are pulled in opposing directions relative to underlying tissue — commonly happening when a patient slides down in a raised bed, stretching and tearing capillaries and deeper structures.
Question 7: Which stage of a pressure injury is characterized by full-thickness tissue loss with exposed or palpable bone, tendon, or muscle?
- Stage 2
- Stage 3
- Stage 4 (Correct answer)
- Unstageable
Correct answer: Stage 4
Stage 4 pressure injuries involve the deepest tissue damage, with full-thickness loss and exposed or directly palpable bone, tendon, or muscle, sometimes with slough or eschar present.
UNAR Skin Care and Pressure Injury Prevention 2
Which nursing assistant action best prevents skin breakdown in a bedridden patient?