A nurse is assessing a 78-year-old patient who has been bedridden for 10 days following hip fracture surgery. Which assessment finding would be the highest priority for immediate nursing intervention?
1Stage 1 pressure ulcer on the coccyx with intact skin and non-blanchable redness
2Dry, flaky skin on the lower extremities with mild scaling
3Small skin tear on the forearm from tape removal during IV insertion
4Stage 2 pressure ulcer on the heel with partial-thickness skin loss and visible dermis✓ 정답
해설
Stage 2 pressure ulcer on the heel indicates partial-thickness skin loss requiring immediate intervention to prevent progression. Other findings (Stage 1 ulcer, dry skin, skin tear) are less urgent.
Clinical Judgment
This question evaluates prioritization and clinical judgment. The core is asking for the "highest priority (immediate nursing intervention)." All options are skin issues, but their severity and urgency differ. Advanced age, immobility, and postoperative status are major risk factors for pressure ulcer development. In this context, a Stage 2 pressure ulcer on the heel indicates that tissue damage has already progressed, posing a high risk of further deterioration and serious infection. The heel, in particular, is an area with poor blood supply and concentrated pressure, making healing difficult and requiring immediate and active intervention. In contrast, a Stage 1 pressure ulcer is an early stage with intact skin, and dry skin or a small skin tear are relatively less urgent issues in the current situation.
Memory Tip:
Prioritization Tip: Think "Progressed Wound in a High-risk Patient." Progressed wound (Stage 2+) + High-risk patient (elderly, immobile) = Top priority.
KR vs US
While pressure ulcer prevention and management are important in Korea, the US NCLEX and clinical settings heavily emphasize the immediacy of intervention based on the pressure ulcer stage and the importance of documentation. Discovering a Stage 2 or higher pressure ulcer is considered a significant event requiring notification of the healthcare provider (Notify HCP) and immediate initiation of a standardized wound care protocol.
Clinical Practice GuideWhen assessing elderly immobile patients, you should systematically evaluate pressure injury risk using tools like the Braden Scale. Especially, thoroughly examine bony prominences such as the heels, sacrum, and ischial tuberosities.
CautionIn SATA (Select All That Apply) questions asking for the "highest priority," be careful of the trap where you must list all skin issues but select only one as the "highest." Also, while Stage 1 pressure injuries (non-blanchable erythema) are important, they are a prevention stage with no skin damage, so the urgency of intervention is lower than for Stage 2 (with skin damage).
Pressure Injury (Pressure Ulcer) — Localized injury to the skin and underlying tissue caused by sustained pressure between a bony prominence and an external surface (e.g., bed, chair). Previously called 'decubitus ulcer'.
Stage 2 Pressure Ulcer — Partial-thickness skin loss with exposed dermis. The wound bed is pink or red, and there may be blistering or shallow depressions. The fat layer is not visible.
Non-blanchable Erythema — Skin redness that does not turn pale (blanch) when pressure is applied with a finger. An indicative sign of a Stage 1 pressure injury.
Braden Scale — Sensory perception, moisture, activity, mobility, nutrition, friction/shear—a tool that assesses pressure ulcer risk across these six categories. The lower the score, the higher the risk.
Heel Pressure Injury — Pressure injury on the heel. This area has limited blood supply and frequent weight-bearing and friction, making healing difficult and prone to rapid deterioration, requiring special care.