1. Which nursing observation will indicate the patient is at risk for pressureulcer formation?

a. The patient has fecal incontinence.

b. The patient ate two thirds of breakfast.

c. The patient has a raised red rash on the right shin.

d. The patient’s capillary refill is less than 2 seconds.

ANS:A

The presence and duration of moisture on the skin increase the risk of ulcer formation by making it

susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal

or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin

breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet

is important for nutrition, but eating just two thirds of themeal does not indicate that the individual

is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it

is located on theshin, which is not a high-risk area for skin breakdown. Pressure can influence

capillary refill, leading to skin breakdown, but this capillary response is within normal limits.

2. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a

patient with a Stage III pressure ulcer. The wound seems

to be healing, and healthy tissue is observed. How should the nurse documentthis ulcer in the

patient’s medical record?

a. Stage I pressure ulcer

b. Healing Stage II pressure ulcer

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c. Healing Stage III pressure ulcer