NUR 221A: Tissue Integrity

Based on knowledge of areas at greatest risk for development of a pressure injury in the bedridden patient, the nurse identifies which position to minimize this risk? a. 30-degree side-lying b. Sitting with the head of the bed elevated 75 degrees c. 90-degree side-lying d. Lying supine with the bed flat at all times

a

On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse? a. The presence of an infection in the area b. The presence of a stage 1 pressure injury c. An allergic reaction to the sheets d. The need to apply a cold compress to reduce inflammation

b

A patient has a stage 3 pressure injury on the coccyx. Which food will be most beneficial in improving the healing process? a. Food high in vitamin D b. Whole-grain carbohydrates c. High-calorie, high-protein drink d. Food high in fat and water content

c

The nurse assesses the vaginal pH of four clients in the obstetrics unit. Which client has normal pH? 1. Client A with pH of 4.2 2. Client B with pH of 6.8 3. Client C with pH of 7.5 4. Client D with pH of 9.3

1

A client with scleroderma reports numbness and tingling in the hands followed by blanching of the fingers. The nurse concludes that the client has Raynaud phenomenon. How should the nurse advise the client? 1. "soak the hands frequently in hot water" 2. "keep the hands warm by wearing gloves" 3. "rub the hands briskly to increase circulation" 4. "take the prescribed anticoagulants to prevent exacerbations"

2

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? 1. the nurse should minimize the use of tape on the skin 2. the nurse should keep the client adequately hydrated 3. the nurse should change the dressings as soon as they get wet 4. the nurse should provide the rest for the client throughout the day

2

While caring for an obese client who underwent a cholecystectomy, the nurse notices a separation in the surgical incision. Which complication does the nurse identify? 1. adhesions 2. dehiscence 3. evisceration 4. contractions

2

Which symptoms are observed in a client with Sjögren's syndrome? Select all that apply. 1. angioedema 2. tooth decay 3. corneal ulcers 4. vaginal dryness 5. pulmonary hemorrhage

2, 3, 4

A client with a long history of bilateral varicose veins questions a nurse about the brownish discoloration of the skin on the lower extremities. What should the nurse include in the response to the client's question? 1. the arterial blood supply is inadequate 2. there is delayed healing in the area after an injury 3. the production of melanin in the area has increased 4. there is leakage of red blood cells (RBCs) through the vascular wall

4

Which statement best describes the healing process for a surgical wound that has been closed with the use of sutures? a. The edges of the wound are approximated. b. New tissue fills the sides and base of the wound. c. The proliferate phase is longer with surgical wounds. d. Debridement aids in the surgical healing process.

a

Which technique is used to collect an aerobic culture specimen from a wound? a. Collect the specimen immediately after removing the old dressing. b. Apply sterile gloves, then open the culture tube. c. Always be sure to culture any necrotic tissue. d. Irrigate the wound before collecting the culture material.

d

A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply. 1. drying of hair 2. drying of surface cells 3. decreased synthesis of vitamin D 4. decreased efficiency to cool the body 5. decreased excretion of waste products through the skin

2, 4, 5

A client receiving chemotherapy asks the nurse why an antibiotic was prescribed. Which tissue affected by chemotherapy should the nurse consider when formulating a response? 1. liver 2. blood 3. bone marrow 4. lymph nodes

3

A client with a reddish-blue generalized skin alteration is hospitalized. Laboratory findings show an increase in the overall amount of hemoglobin. Which condition might the nurse suspect? 1. albinism 2. addison's disease 3. polycythemia vera 4. methemoglobinemia

3

Which integumentary manifestation can be noticed in a client with CD4+ count of 180/mm 3/(200/uL)? 1. bruises 2. cyanosis 3. flushed and dry skin 4. delayed wound healing

4

Which patient is at highest risk for impaired wound healing? a. A 22-year-old with a pelvic fracture incurred in a motor vehicle accident b. A 49-year-old with a history of smoking two packs a day who just had abdominal surgery c. A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip d. A 90-year-old with no chronic health conditions with a small blistered burn on the hand

c

Four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his abdominal wound. An increase in amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. Which are the priority nursing interventions? (Select all that apply.) a. Apply Steri-Strips to close the wound edges. b. Cover the wound with saline-moistened gauze c. Apply a binder to pull the wound edges together and provide support to the edges. d. Notify the physician. e. Allow the area to be exposed to air until all the drainage has stopped.

b, d

A patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient's greatest risk factor for development of pressure injuries? a. Moisture from incontinence b. Nutritional deficiencies c. Pressure and shear d. Aging

c

Which skin-care interventions should be initiated by the nurse caring for a patient with urinary or fecal incontinence? (Select all that apply.) a. Changing the adult brief every 8 hours b. Cleansing frequently with hot water and a strong soap c. Using an incontinence cleanser d. Frequent position changes e. Applying a moisture barrier ointment

c, d, e

Which features are characteristic of a closed drainage system, such as a Jackson-Pratt (JP) drain? (Select all that apply.) a. Works by gravity b. Provides for early discharge c. Usually is inserted in surgery d. Reduces the amount of antibiotics required e. Allows for accurate measurement of wound drainage

c, e