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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 leavesÂ
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