Tissue Integrity PrepU

The nurse is planning care for an older adult with a pressure ulcer. What should the nurse do? Select all that apply. a) Reposition the client every 2 hours. b) Request an alternating-pressure mattress. c) Elevate the head of the bed to 50 degrees. d) Obtain daily cultures. e) Cover with protective dressing

A, B, E

A day-shift nurse tells a night-shift nurse that she has been attempting to reduce the risk for Impaired skin integrity related to immobility in a toddler. Which statement by the night-shift nurse should the day-shift nurse question? Select all that apply. a) "I'll wipe the pressure points with alcohol wipes to keep them clean." b) "I'll change the toddler's position frequently." c) "I'll gently massage the skin with a lubricating substance." d) "I'll clean the skin as often as necessary.

A and C

The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply. a) "Use an electric blanket when you are sleeping." b) "Wear extra socks in the winter." c) "Avoid sunburn during the summer." d) "Warm the fingers or toes by using an electric heating pad." e) "Choose loose, soft, cotton socks."

B, C, E

An older adult who is to be on bed rest has become incontinent of urine. To prevent pressure ulcers, the nurse should do which tasks? Select all that apply. a) Anchor a Foley catheter. b) Inspect the groin for wetness. c) Use a sanitary napkin to absorb urine. d) Institute a turning schedule. e) Have client wear incontinence briefs

B, D, E

Which disciplines should be consulted when caring for a client with a stage III heel ulcer? a) Nutrition support and orthotics b) Occupational therapy and infectious disease c) Plastic surgery and cardiology d) Physical therapy and respiratory therapy

a) nutrition support and orthotics

Which client is at increased risk for developing a wound infection? a) A client that does not ambulate on first post-op day. b) A client with an albumin level of 2.4 g/dl. c) A client with a hemoglobin of 11.4. d) A client with a body mass index (BMI) of 27.

b) a client with albumin level of 2.4 g/dl

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: a) reduces edema. b) enhances protein synthesis. c) restores the inflammatory response. d) enhances oxygen transport to tissues

b) enhances protein synthesis

A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care? a) "I should inspect my feet at least once a week." b) "When I injure my toe, I will plan to put iodine on it." c) "It is okay to go barefoot in the house." d) "It is important to dry my feet carefully after my bath."

d) "It is important to dry my feet carefully after my bath."

When a client has a tearing of tissue with irregular wound edges, the nurse should document this as: a) contusion. b) abrasion. c) colonization. d) laceration

d) laceration

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? a) The wound drainage is serous. b) The tissue surrounding the wound is red and hot. c) The skin around the wound is edematous. d) The granulation tissue is at the wound edges.

d) the granulation tissue is at the wound edges

A client is to have radiation therapy after a modified radical mastectomy. The nurse should teach the client to care for the skin at the site of therapy by: a) exposing the area to dry heat. b) using talcum powder on the area. c) applying an ointment to the area. d) washing the area with water.

d) washing the area with water

Which substance should the nurse include in the teaching plan for a teenager with acne who has requested information about cleansing the affected skin? a) witch hazel b) hydrogen peroxide c) baby lotion d) soap and water

d) soap and water

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to: a) use herbal supplements. b) encourage frequent passive range-of-motion to the affected extremity. c) ask the health care provider (HCP) for a change of antibiotics. d) eat a diet high in protein and vitamins C and D.

d) eat a diet high in protein and vitamins C and D

Which night clothes would the nurse recommend for an infant with atopic dermatitis? a) two-piece flannel pajamas with short sleeves b) one-piece cotton pajamas with long sleeves c) a diaper and short-sleeved shirt d) a woolen sleeper with feet and mittens

b) one-piece cotton pajamas with long sleeves

The nurse is assisting in the birthing room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate childbirth. Which interventions should the nurse perform when caring for the client after this procedure? Select all that apply. a) Administer pain medication, as prescribed. b) Apply ice to the perineum. c) Check the episiotomy repair site. d) Change the dressings every shift. e) Explain perineal care to the client when she can focus on the instructions.

A, B, C, E

A client with cancer has diarrhea and inflamed areas of skin around the rectum. What actions should the nurse take? Select all that apply. a) Use sitz baths. b) Apply zinc oxide ointment to the rectal area after each bowel movement. c) Increase fluid intake. d) Clean the rectal area with unscented soap and water after each bowel movement, rinse well, and pat dry. e) Apply a skin-barrier dressing daily to the rectal area

A, C, D

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. a) Use commercial soaps to keep the skin dry. b) Perform range-of-motion exercises. c) Reposition the client every 2 hours. d) Tuck bed covers tightly into the foot of the bed. e) Encourage the client to eat a well-balanced diet.

B, C, E

A nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do? a) Massage the left leg with alcohol to stimulate circulation. b) Instruct the client to elevate the left leg when sitting in the chair. c) Cleanse the left lower leg with perfumed liquid soap. d) Encourage the client to ambulate in the halls on the unit.

b) instruct the client to elevate the left leg when sitting in the chair

Which nutritional deficiency may delay wound healing? a) Lack of calcium b) Lack of vitamin C c) Lack of vitamin E d) Lack of vitamin D

b) lack of vitamin C

What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy? a) Antibiotics will need to be taken for 1-2 weeks. b) Arm exercises will get rid of the cellulitis. c) Ice pack should be applied to the affected area for 20 minute periods to reduce swelling. d) The right extremity should be lowered to improve blood flow to the forearm.

a) antibiotics will need to be taken for 1-2 weeks

When teaching the diabetic client about foot care, the nurse should instruct the client to: a) avoid going barefoot. b) buy shoes a half size larger. c) use heating pads for sore feet. d) cut toenails at angles.

a) avoid going barefoot

A frail elderly client with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is assisting the client's family to place the mattress (see image). What should the nurse instruct the family to do? a) Make the bed with the bed sheet on top of the pressure mattress. b) Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. c) Make the bed, and then remove the pillow to allow full use of the mattress on the neck. d) Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad.

a) make the bed with the bed sheet on top of the pressure mattress

Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client for: a) postoperative confusion. b) delayed wound healing. c) malnutrition. d) emboli.

b) delayed wound healing

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? a) Bathe daily. b) Shift your weight every 15 minutes. c) Move from the bed to the wheelchair every 2 hours. d) Eat a high-carbohydrate diet.

b) shift your weight every 15 minutes

The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching? a) "I can apply an over-the-counter cortisone ointment to relieve the dryness." b) "I should take antihistamines to decrease the itching I am experiencing." c) "A heating pad, set on the lowest setting, will help decrease my discomfort." d) "It is safe to apply a nonperfumed lotion to my skin."

d) "It is sage to apply a non perfumed lotion to my skin."

A client who has had a bowel resection comes to the health center 7 days postoperatively for removal of the staples. As the nurse is cleansing the incision, the client reports of mid-incision pain. After removing three staples, the nurse observes that the incision is separating. What is the nurse's priority action? a) Remove the remaining staples, apply butterfly tapes, and document the findings. b) Apply butterfly tapes to the separated area and redress the wound immediately. c) Apply warm compresses to the painful area before removing the remaining staples. d) Stop the staple removal, cover the incision, and report the findings to the physician.

d) Stop the staple removal, cover the incision, and report the findings to the physician.

A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair in no evident distress with the legs in a dependent position. The nurse should first: a) take the client's blood pressure b) request a prescription for support stockings c) assist the client to bed d) elevate the client's legs on a foot stool

d) elevate the clients legs on a foot stool

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) ice cream. b) fresh orange slices. c) steamed broccoli. d) ground beef patties.

d) ground beef patties

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize? a) Legumes and cheese b) Fruits and vegetables c) Whole grain products d) Lean meats and low-fat milk

d) lean meats and low-fat milk

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected? a) warmth in the foot b) thin, soft toenails c) loss of hair on the lower leg d) edema around the ankle

c) loss of hair on the lower leg

When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer? a) presence of hypertension b) exposure to moisture c) the client's gender d) smoking

b) exposure to moisture

The nurse uses Montgomery straps primarily so the client is free from: a) falls. b) bruises. c) skin breakdown. d) wandering.

c) skin breakdown

A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed? a) Apply the saturated fine-mesh gauze dressings over the wound. b) Apply an occlusive dressing over the saturated fine-mesh gauze dressings. c) Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. d) Cover the saturated fine-mesh gauze dressings with an elastic bandage.

c) pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound

The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? a) Turn the client every 2 to 4 hours. b) Place a foam pad on the existing mattress. c) Place the client on a pressure redistribution bed. d) Administer pain medications as ordered.

c) place the client on a pressure redistribution bed

An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: a) provide for permanent wound closure. b) facilitate development of subcutaneous tissue. c) promote the growth of epithelial tissue. d) encourage formation of tough skin.

c) promote the growth of epithelial tissue

A client receiving chemotherapy has pruritus. In order to develop a care plan, the nurse should ask if the client has been: a) sleeping in a cool, humidified room. b) wearing clothes made from 100% cotton. c) taking daily baths with a deodorant soap. d) increasing fluid intake to at least 3,000 mL per day

c) taking daily baths with a deodorant soap

A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which information should the nurse include in client teaching? a) Place ice on the area after each treatment. b) Use a heating pad under the right arm. c) Apply deodorant only under the left arm. d) Immobilize the right arm.

c) apply deodorant only under the left arm

During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The health care provider's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply. a) Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved. b) The skin is infected wherever the rash has developed. c) The disorder is contagious. d) Based on the location, it is likely that detergents in the bed linens caused the rash. e) This is an allergic reaction. f) Washing with antibacterial soap will help the rash.

A, D, E

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? a) Urine output of 20 ml/hour b) Rectal temperature of 100.6° F (38° C) c) Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg d) White pulmonary secretions

a) urine output of 20 mL/hour

The nurse plans to teach a client who is receiving radiation therapy how to care for the skin at the radiation site. What should the nurse tell the client? a) "You may use deodorant soap if you wish to cleanse the area." b) "Keep the area covered when you go outdoors." c) "Put baby oil on the area after each treatment to keep it from getting dry." d) "Apply a heating pad to the area to relieve pain

b) "Keep the area covered when you go outdoors."

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour care ride, what should the nurse should advise the client to do? a) Elevate her legs while riding in the car. b) Perform ankle pumps and foot range-of-motion exercises. c) Perform arm circles while riding in the car. d) Take an ambulance home.

b) perform ankle pumps and food ROM exercises

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority for this client after the stockings are applied? a) Order a second pair of stockings to be rotated each day. b) Remove elastic stockings once per day and observe lower extremities. c) Elevate the client's legs while out of bed. d) Teach the client isotonic leg exercises.

b) remove elastic stockings once per day and observe lower extremities

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? a) "The drainage contains enzymes that are necessary for wound healing." b) "The drainage is an indication that the sutures were not tight enough." c) "If a wound heals on the surface but infection remains, it will open and drain." d) "Antibiotics cause the cells of the tissues to produce purulent drainage.

c) "If a wound heals on the surface but infection remains, it will open and drain."

When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch? a) pasta salad, carrots, and milk b) hamburger, orange, and coffee c) chicken breast, salad, and iced tea d) roast beef sandwich, milkshake, and cottage cheese

d) roast beef sandwich, milkshake, and cottage cheese

A middle-aged female with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which action should the nurse suggest? a) Schedule an appointment within 2 to 3 weeks. b) Apply warm compresses to the affected arm. c) Elevate the arm on two pillows. d) See the (HCP) immediately.

d) see the HCP immediately

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1? × 1? (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a) stage IV pressure ulcer b) stage III pressure ulcer c) stage I pressure ulcer d) stage II pressure ulce

d) stage II pressure ulcer

When planning for risk management for clients who are at risk for development of pressure ulcers, the nurse should first: a) automatically place clients in specialty beds. b) provide at-risk clients with a high-protein, high-carbohydrate diet. c) identify at-risk clients on admission to the health care facility. d) place at-risk clients on an every-2-hour turning schedule

c) identify at-risk clients on admission to health care facility

Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns? a) excessive bleeding b) blanching to the touch c) minimal pain d) blistering and a moist appearance

c) minimal pain

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a) institute (ROM) exercise every 4 hours. b) massage the abdomen once a shift. c) use an alternating air pressure mattress. d) elevate the lower extremities.

c) use an alternating air pressure mattress

The nurse is instructing a client about skin care while receiving radiation therapy to the chest. What should the nurse instruct the client to do? a) Shave the chest to prevent contamination from chest hair. b) Apply lotion if the skin becomes dry. c) Wash the area with tepid water and mild soap. d) Keep the area covered with a non-adherent dressing between treatments.

c) wash the area with tepid water and mild soap

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception? a) Tattoos are easily removed with laser surgery. b) Human immunodeficiency syndrome (HIV) is a possible risk factor. c) Hepatitis B is a possible risk factor. d) Allergic response to pigments is a possible risk factor.

a) tattoos are easily removed with laser surgery

A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to: a) apply a moist-to-moist dressing, being careful to pack just the wound bed. b) reposition the client off the reddened skin and reassess in a few hours. c) consult with a wound-ostomy-continence nurse specialist. d) complete and document a Braden skin breakdown risk score for the client

b) reposition the client off the reddened skin and reassess in a few hours

The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first? a) Contact the health care practitioner (HCP) to request a hydrocolloid dressing. b) Make a home visit to verify the changes in the ulcer. c) Instruct the home health aide to reposition the client every 2 hours while the client is awake. d) Ask the client's daughter to purchase a foam mattress.

a) contact the HCP to request a hydrocolloid dressing

A nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should she proceed? a) Rapidly instill a stream of irrigating solution into the wound. b) After the irrigation, moisten the area around the wound with normal saline. c) After the irrigation, apply a wet-to-damp dressing to the wound. d) Irrigate continuously until the solution becomes clear.

d) irrigate continuously until the solution becomes clear

A child with partial- and full-thickness burns is admitted to the pediatric unit. What should be the priority at this time? a) managing the child's pain b) preventing wound infection c) evaluating vital signs frequently d) maintaining fluid and electrolyte balance

d) maintaining fluid and electrolyte balance

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? a) IV fluid infusion rate b) capillary refill c) nasal cannula flow rate d) pedal pulses

d) pedal pulses