ATI: Tissue Integrity

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. a. Hyperlipidemia b. Diabetes mellitus c. Medication history d. Cholesterol level e. Prealbumin level

b. Diabetes mellitus c. Medication history e. Prealbumin level Diabetes mellitus causes a decrease in tissue perfusion and impaired sensation, which increases the risk for delayed wound healing. Corticosteroids decrease the formation of collagen and fibroblasts which are needed for wound healing. The client's prealbumin level is below the expected reference range which indicates malnutrition. Malnutrition places the client at risk for impaired wound healing and tissue integrity due to a decrease in essential nutrients. Nutrients, such as protein, vitamins A and C, and fatty acids are necessary for wound healing.

A nurse is teaching a class about the function of cells in the epidermis. The nurse should include that which of the following cells determine skin color? a. Merkel cells b. Melanocytes c. Keratinocytes d. Langerhans cells

b. Melanocytes Melanocytes produce melanin that determines skin and hair color. Melanocytes absorb radiant energy from the sun and protect the skin from ultraviolet radiation.

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increase the client's risk of a pressure injury? a. BMI of 20 b. Peripheral neuropathy c. Immobility d. Hypoperfusion e. Prealbumin level of 16 mg/dL

b. Peripheral neuropathy c. Immobility d. Hypoperfusion Peripheral neuropathy increases the client's risk for pressure injury due to a decrease in pain related to pressure sensation. Immobility increases the client's risk for a pressure injury due to a decreased ability to reposition off bony prominences. Hypoperfusion increases the client's risk for a pressure injury due to decreased circulation in tissues

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? a. Massage the client's bony prominences. b. Provide the client with a high-calorie diet. c. Elevate the head of the client's bed 45° d. Reposition the client every 4 hr.

b. Provide the client with a high-calorie diet. The nurse should provide the client with a high-calorie diet to promote wound healing and strengthen tissue to reduce the risk for a pressure injury.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. a. Wound bed is red. b. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted c. Temp 38.9° C (102° F) d. Hct 37% (37% to 47%) e. WBC 13,500/mm3 (5000 to 10,000 mm3)

b. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted c. Temp 38.9° C (102° F) e. WBC 13,500/mm3 (5000 to 10,000 mm3) The nurse should identify that redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted, temp 38.9° C (102° F), and WBC 12,000/mm3 (5000 to 10,000 mm3) are associated with worsening of the client's condition and require follow-up. The condition of the client's pressure injury and the client's temperature and WBC count on day 4, indicate manifestations of an infection. The nurse should report these findings to the provider. The client might require a wound culture, wound irrigation, and antibiotics. Wound bed is red and the client's Hct 38% (37% to 47%) The client's pressure injury on day 1 has no evidence of infection. A red wound bed indicates a viable wound and the client's Hct is within the expected reference range. These findings do not require further action by the nurse.

A nurse is reviewing the medical history of a client who is scheduled for surgery. Which of the following findings places the client at risk for an incisional hematoma? a. The client has urinary incontinence. b. The client takes anticoagulant medications. c. The client has peripheral vascular disease. d. The client is underweight.

b. The client takes anticoagulant medications. Anticoagulant medications interfere with blood clotting mechanisms and place the client at risk for a hematoma.

A nurse is teaching a newly licensed nurse about reducing the risk for healthcare-associated infections. Which of the following instructions should the nurse include? a. Irrigate indwelling urinary catheters daily. b. Use chlorhexidine gluconate to clean skin on clients who are preoperative. c. Provide mouth care every 8 hrs for clients who require mechanical ventilation. d. Change a gauze dressing over central vascular access devices every 3 days.

b. Use chlorhexidine gluconate to clean skin on clients who are preoperative. The nurse should use chlorhexidine gluconate to clean skin on clients who are preoperative to reduce the risk for healthcare-associated infections.

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound? a. Hydrofiber dressing b. Alginate dressing c. Film dressing d. Foam dressing

c. Film dressing Film dressings or self-adhesive transparent dressings are used to cover superficial wounds that have minimal exudate.

A nurse is planning care for a client who has an infected wound with significant exudate. The nurse should plan to use which of the following dressings to cover the wound? a. Hydrogel dressing b. Hydrocolloid dressing c. Hydrofiber dressing d. Polymeric membrane dressing

c. Hydrofiber dressing Hydrofiber dressings are used for moderate and highly exudative wounds. Hydrofiber dressings provide high absorbency and can stay in the wound for several days.

A nurse is teaching a class about the function of cells in the epidermis. The nurse should include that which of the following are receptor cells that detect light touch? a. Langerhans cells b. Melanocytes c. Merkel cells d. Keratinocytes

c. Merkel cells Merkel cells are receptor cells that detect light touch. They are primarily located in the palms of the hands and soles of the feet.

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take? a. Connect the drain to continuous low-pressure suction. b. Clean the skin near the drain in a circular motion from the outside to the inside. c. Place a perforated gauze pad around the drain. d. Empty the drainage device when it is half full.

c. Place a perforated gauze pad around the drain. The nurse should place a perforated gauze pad around the drain to collect fluids from the drain.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? a. A client who is receiving enteral feeding and can change position independently. b. A client who alert and responsive and eats 25% of each meal. c. A client who makes frequent slight changes in position and walks occasionally. d. A client who is unresponsive to verbal commands and changes position occasionally.

d. A client who is unresponsive to verbal commands and changes position occasionally. This client is at greatest risk for a pressure injury because they have a very limited sensory perception. The nurse should monitor the client for a pressure injury.

A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take? a. Irrigate the wound until the solution that is draining is clear. b. Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating. c. Chill the irrigant prior to the procedure. d. Flush the wound from the most contaminated area to the cleanest area.

a. Irrigate the wound until the solution that is draining is clear. The nurse should flush the wound until the solution that is draining is clear because this indicates all the debris is removed from the wound.

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect? a. Partial-thickness skin loss with red tissue in wound bed. b. Full thickness skin loss with visible bone c. Intact skin with localized erythema. d. Full thickness skin loss with visible adipose tissue.

a. Partial-thickness skin loss with red tissue in wound bed. Partial-thickness skin loss with red or pink viable tissue in wound bed is a stage 2 pressure injury.

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? a. Vomiting b. Hypoglycemia c. Hypertension d. Altered mental status e. Elevated WBC's count

a. Vomiting d. Altered mental status e. Elevated WBC's count Manifestations of a systemic infection include altered mental status, elevated WBC's count, nausea, vomiting, chills, and fever.

A nurse is caring for a client who has a wound that requires negative pressure wound therapy. Which of the following actions should the nurse take? a. Shave hair on the client's skin surrounding the wound. b. Cut a round hole in the center of the outer dressing. c. Expect the inner dressing to expand after the vacuum pump is initiated. d. Cover the client's wound with an alginate dressing.

b. Cut a round hole in the center of the outer dressing. The nurse should cut a 2.5 cm (1 in) round hole in the center of the outer dressing to allow for insertion of the drainage tube.

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? a. Decreased serum calcium b. Decreased circulation c. Increased collagen d. Increased muscle mass

b. Decreased circulation The client who is immobile is at risk for a pressure injury due to decreased circulation to tissues.

A nurse is planning care for a client who has urinary incontinence. The nurse should plan to monitor the client for which of the following findings? a. Fluid volume overload b. Dermatitis c. Kidney stones d. Hypoglycemia

b. Dermatitis A client who has urinary incontinence is at risk for incontinence-associated dermatitis and impaired tissue integrity.

A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first? a. Don sterile gloves b. Place the collection tube in a specimen bag. c. Swab the wound bed with a sterile cotton-tipped swab d. Cleanse the area around the wound with sterile saline.

d. Cleanse the area around the wound with sterile saline. Evidence-based practice indicates the first action the nurse should take is to cleanse the area around the wound with sterile saline. Cleansing the area loosens necrotic tissue and exposes the wound bed to reduce the risk of obtaining a contaminated specimen.

A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take? a. Clean the client's skin with hot water. b. Restrict the client's fluid intake. c. Apply baby powder to the client's skin. d. Dry between folds in the client's skin.

d. Dry between folds in the client's skin. The nurse should dry between the client's skin folds to decrease moisture and reduce the risk of a pressure injury.

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss? a. Maturation b. Proliferation c. Remodeling phase d. Inflammation

d. Inflammation Inflammation is the process that occurs during the first phase of wound healing which is also known as the inflammatory or hemostatic phase. During this phase, blood vessels constrict and clotting factors are activated.

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect? a. Healing of the wound is prolonged. b. Granulation tissue forming at the bottom of the wound bed. c. Wound is contaminated at the time of injury. d. Skin edges of the wound are sutured closed.

d. Skin edges of the wound are sutured closed. Wound healing by primary healing or first intention is a clean laceration, such as a surgical incision, that is closed by sutures or skin adhesives.

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at greatest risk for developing ___1.___ due to ___2.___. 1. Muscle loss 1. Pressure Injury 1. Foot droop 2. Bowel sounds 2. Urinary Incontinence 2. Calcium level

1. Pressure Injury 2. Urinary Incontinence The nurse should analyze the findings and determine the greatest risk to this client is a pressure injury from urinary incontinence and immobility. Therefore, the priority intervention the nurse should take is to implement interventions to reduce the risk for a pressure injury, such as applying a moisture barrier to protect the skin, frequent repositioning and skin evaluation.

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect? a. Intact skin with localized erythema b. Full thickness skin loss with visible adipose tissue. c. Full thickness skin loss with visible bone d. Partial-thickness skin loss with red tissue in wound bed

a. Intact skin with localized erythema Intact skin with localized erythema is a stage 1 pressure injury.

A nurse is teaching a class about expected changes to the skin in older adults. Which of the following information should the nurse include? a. Increase in skin thinning b. Increase in skin elasticity c. Decrease in subcutaneous tissue d. Increase in blood supply to skin e. Decrease in skin hydration

a. Increase in skin thinning c. Decrease in subcutaneous tissue e. Decrease in skin hydration Expected changes to the skin that occur with aging can include thinning of the skin. Therefore, older adults are at an increased risk of injury to the skin. Expected changes to the skin that occur with aging can include a decrease in subcutaneous tissue. Therefore, older adults are at an increased risk of injury to the skin.