While we may (un-) lovingly deride the NCLEX for its structure (the most correct answer, anyone?), it does do a good job of evaluating nursing judgement and showing what/how you should be thinking while nursing.
And it doesn’t stop with the NCLEX. Every certification exam you take is built on the same structure. Yay. So, let’s practice and check our knowledge at the same time.
Skin, skin, skin! Everywhere you work will be obsessed with skin. Might as well get used to it now.
What is the best nursing action for a patient who needs assistance to turn and has red, nonblanchable skin over the sacrum?
A. Frequent repositioning and skin assessments
B. Notification of the physician to request a wound expert consult
C. Applications of a topical antimicrobial to the sacrum
D. Measurement of the redness and application of a foam dressing
Source: Critical Care Nurse, Vol. 43, No. 2
So, this is one of those ‘most correct’ questions. Because most of the answers are things you do will want to do. You just need to know the first, best thing to do.
Immediately, I can remove Option B. Calling the doctor is never the answer. Even if something is critical, there is always a nursing intervention you can do first to stabilize the patient. Yes, you should get a wound consult for this Stage 1 pressure ulcer, but you can do more than that.
Option C is also iffy. Because the redness is unblanchable, it is unlikely to be from a local infection. There is no other indication we are dealing with a soft tissue infection. Unblanchable tissue means the vessels that feed the area have been damaged from pressure, rather than erythema related to local vasodilation, contact dermatitis, or a yeast rash. No infection = no antimicrobial.
Yes, absolutely you want to measure the affected area, as in Option D. But applying a foam dressing many not be appropriate, depending on the extent of the injury and the patient’s other needs. And often if something is covered up, it won’t get assessed as frequently as it needs to be.
Which leaves us Option A, frequent repositioning and skin assessments. Pressure injuries will continue to evolve unless we remove the mechanism. That means turning the patient left to right, not leaving supine unless for eating or other care, and checking their skin all of the times. You will get real familiar with their booty, because you need to know if this ulcer begins to advance.
Even with your excellent nursing care and intervention, the ulcer might get worse anyway. Deep tissue injuries can develop slowly and break through the surface days after the initial injury. Keep a close eye on it and get that patient out of bed if possible.
***Pro tip: Assessment is the first step of the nursing process, so if an option to assess is available, that’s usually what you should do first.
How’d you do? Questions? Confusion? Too easy? Comment and let me know if you have any sore spots you want to review.
References
Porth’s Pathophysiology: Concepts of Altered Health States (9th Edition). Grossman, S.C., Porth, C.M.
Critical Care Nurse, Vol. 43 No. 2, April 2023. Certification Test Prep
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Enjoy!
Anna, RN, BSN, CCRN
Necessary disclaimer: I am discussing medications and medical conditions in this article based on my personal experiences as a nurse. Your facility may have different requirements and resources. Use your own nursing judgement to assess and treat your patients according to your governing body and facility guidelines. All information within this article is correct to the best of my knowledge, but should be confirmed through verified evidence-based sources. I am not responsible for any clinical decisions made based on this article.