Prep U Practice Questions (Tissue Integrity)

Which nursing intervention can help a client maintain healthy skin? Keeping the client well hydrated Avoiding bathing the client with mild soap Removing adhesive tape quickly from the skin Recommending wearing tight-fitting clothes in hot weather

Keeping the client well hydrated Explanation: Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.

A hospitalized patient has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? fever, joint pain, dehydration poor wound healing, apathy, edema sleep disturbances, anger, increased output weight gain, visual deficits, erythema of skin

poor wound healing, apathy, edema Explanation: The stress of illness, surgery, or prolonged periods of time on simple intravenous therapy without oral intake places hospitalized patients at risk for developing protein-calorie malnutrition, resulting in weakness, poor wound healing, mental apathy, and edema.

The nurse is caring for a client who has paraplegia following a hunting accident. The nurse knows to assess regularly for the development of pressure ulcers on this client. What rationale should the nurse cite for this nursing action? The client likely has a decreased level of consciousness. The client may not be motivated to prevent pressure ulcers. The risk for pressure ulcers is directly related to the duration of immobility. The risk for pressure ulcers is related to what caused the immobility.

The risk for pressure ulcers is directly related to the duration of immobility. Explanation: The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration of the immobility is what matters. Paraplegia does not result in a decreased level of consciousness and there is no reason to believe that the client does not want to prevent pressure ulcers.

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin? E D A C

D Explanation: Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus.

Which is a priority nursing assessment of a reddened heel in a bed-ridden client? Test for blanching to the affected area. Rub the reddened area above and below the site. Check for perspiration and remove all linen to the extremity. Use powder to minimize shear forces to both heels.

Test for blanching to the affected area. Explanation: When a fingertip is pressed over the reddened area and the area does not blanch but remains consistently reddened, it is an indication of deep tissue injury. The other choices are not appropriate ways to treat a reddened area.

Which sentence correctly describes the prone position? The body is supine. Arms are elevated at shoulder level. The body is facedown. The body is facing backward.

The body is facedown. Explanation: In the prone position, the body is facedown with the head to the side.

A nurse is viewing a list of clients. Which clients would the nurse anticipate to be at risk for skin breakdown? Select all that apply. a 60-year old client post cardiac catheterization a 30-year old client with a fractured L3-L4 an 80-year old client with incontinence of urine a 25-year old client with an ankle sprain a 50-year old client with a newly diagnosed stroke

a 30-year old client with a fractured L3-L4 an 80-year old client with incontinence of urine a 50-year old client with a newly diagnosed stroke Explanation: The client with the fracture to the lumbar area (L3 & L4) and the one with a newly diagnosed stroke will have difficulty with mobility, causing a risk for skin breakdown. The client with incontinence has a risk for skin breakdown due to moisture. While the client with the fractured ankle has mobility problems, the client is young and will be able to move without risk for skin breakdown. The client who had a cardiac catheterization may have mobility issues for a short time but also doesn't have a significant risk for skin breakdown due to this.

The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage? white with sanguineous drainage clear, watery, yellow-tinged drainage tenacious and yellow drainage dark melena and foul smelling

clear, watery, yellow-tinged drainage Explanation: Serous drainage is clear, watery plasma; sanguineous drainage is fresh, red bleeding; purulent drainage is thick and yellow; and purulent drainage with infection is beige to brown and foul smelling. White with sanguineous drainage and tenacious with yellow drainage are both indicative of an infection. Dark melena and foul smelling is indicative of a gastrointestinal bleed.

A nurse is changing a client's surgical incision dressing on post-op day three. For which observation would the nurse take immediate action? reddened wound edges small amount of creamy yellow drainage moderate pinkish to red watery drainage epithelizing tissue present

small amount of creamy yellow drainage Explanation: Yellow, creamy drainage describes purulent discharge and suggests infection; the nurse must report this finding to the healthcare provider immediately and obtain a culture as ordered. Clear pink to red watery discharge describes serosanguinous discharge, which is evidence of some edema at the site; it does not warrant immediate intervention. Reddened wound edges are expected as healing occurs, and epithelizing tissue represent normal findings for a wound.