1. The nurse is caring for a patient who is at risk for skin impairment. The patient

is able to sit up in a chair. The nurse includes this intervention in the plan of care.

How long should the nurse schedule the patient to sit in the chair?

a. At least 3 hours

b. Less than 2 hours

c. No longer than 30 minutes

d. As long as the patient remains comfortable

ANS: B

When patients are able to sit up in a chair, make sure to limit the amount of time to

2 hours or less. The chair sitting time should be individualized. In the sitting

position, pressure on the ischial tuberosities is greater than in a supine position.

Utilize foam, gel, or an air cushion to distribute weight. Sitting for longer than 2

hours can increase the chance of ischemia.

2. The nurse is caring for a patient who is immobile and is at risk for skin

impairment. The plan of care includes turning the patient. Which is the best

method for repositioning the patient?

a. Place the patient in a 30-degree supine position.

b. Utilize a transfer device to lift the patient.

c. Elevate the head of the bed 45 degrees.

d. Slide the patient into the new position.

ANS: B

When repositioning the patient, obtain assistance and utilize a transfer device to

lift rather than drag the patient. Sliding the patient into the new position will

increase friction. The patient should be placed in a 30- degree lateral position, not

a supine position. The head of the bed should be elevated less than 30 degrees to

prevent pressure ulcer development from shearing forces.

3. A nurse is assigned most of the patients with pressure ulcers. The nurse leaves