HESI: Skin Integrity
After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal will the nurse include in Aaron's plan of care? A) Client's skin will remain intact B) Client's motor function will be restored C) Client teaching will be provided D) Impaired skin integrity will not occur
A) Client's skin will remain intact Rationale: A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.
Upon learning that Aaron has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take? A) Encourage him to continue to use this device in his wheelchair at all times. B) Recommend that he replace the gel pad with a donut-shaped foam cushion. C) Advise him to avoid the use of any form of pressure cushion on his wheelchair. D) Teach him that regular skin moisturizer is more important than cushion use.
A) Encourage him to continue to use this device in his wheelchair at all times. Rationale: These cushions help redistribute weight so that is is no all on the ischium. The client should also be instructed to shift weight frequently.
The RN teaches Aaron to apply a dressing over the sacral area. Which type of dressing is most likey to be used of the stage 1 pressure ulcer? A) Transparent film dressing B) Adherent film dressing C) Gauze dressing D) Hydrogel covered with a foam dressing.
A) transparent film dressing. Rationale: This type of dressing allows for visualization of the area and protects it from shear.
The nurse plans to administer a prescribed does of linezolid (ZYVOX), an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The prescribed states, "ZYVOX suspension 600 mg PO q12h for 14 days." The medication is labeled, "100 mg/5 ml)." How many mL of medication will the nurse administer?
D) 30 600mg x (5mL/100 mg) = 30 mL
Considering Aaron's developmental stage, the nurse's plan of care emphasizes interaction with which group? A) Aaron's parents, aunts, uncles, and cousins. B) A large group of Aaron's former high school classmates C) A small group of Aaron's professors from the college D) Aaron's girlfriend and his two best male friends from college.
D) Aaron's girlfriend and his two best male friends from college. Rationale: As a young adult, Aaron's primary developmental task, according to the theorist Erikson, is to develop intimacy. The RN should emphasize interaction with a small group of intimate friends to support this developmental task.
After receiving the first Linezolid, Aaron develops a rash and itching on his thorax, but no respiratory symptoms. Which class of medication should the nurse expect to administer? A) An anticholinergic medication, such as atropine B) An adrenergic medication, such as epinephrine (Adrenalin) C) An antipyrectic medication, such as acetaminophen (Tylenol) D) An antihistamine, such diphenhydramine (Benadryl)
D) An antihistamine, such diphenhydramine (Benadryl) Rationale: An antihistamine should control the itching and rash of this reaction. Rash and itching are identified side effects of linezolid. The RN should, however, continue to monitor for a more severe allergic response.
Aaron has been receiving antibiotic therapy for several days. He has a mild elevation in blood pressure and a 2x2 cm bruise in the antecubital space, where blood was obtained earlier that day, and has had two diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatotoxicity related to antibiotic use. Which diagnostic test should the nurse request a prescription for to determine if Aaron is develop drug toxicity? A) Culture and sensitivity B) Therapeutic index C) Half life D) Peak and trough
D) Peak and trough Rationale: serum drug levels are obtained at the highest (peak) and lowest (trough) levels,which provides useful information regarding the amount of drug the individual client as in the bloodstream. Id the trough is greater that the acceptable limit for the drug, the next dose should be withehld and the blood level rechecked 6 hour later.
The sacral area has remained red for two hours and does not blanch when tested. How will the nurse document this finding? A) Excessive pallor B) Unusual skin mottling C) Dependent sacral rubor D) Reactive hyperemia
D) Reactive hyperemia Rationale: reactive hyperemia occurs when tissue is relieved of pressure. Is is considered abnormal when the redness lasts longer than 1 hour and the surrounding tissue does not blanch.
Prior to administering the first does of the antibiotic, the nurse asks Aaron about any drug allergies. The nurse explains to Aaron that this precaution reduces the risk for what potential problem? A) Anaphylactic reaction B) Idiosyncratic response C) Drug tolerance D) Resistance to the antiobiotic
A) Anaphylactic reaction Rationale: An anaphylactic reaction is severe allergic response that can be life-threatening.
The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 g0 1200 mg. What is the total daily dosage that Aaron will be receiving? A) 400 mg B) 600 mg C) 1200 mg D) 1400 mg
C) 1200 mg 600 q12h = 600 * 2 = 1200 mg
The nurse teaches Aaron to apply a transparent film dressing over the sacral area and advises him to follow which schedule for dressing changes? A) Twice daily B) Once daily C) Every third day D) Once weekly
D) Once weekly
Which intervention is important to reduce the effect of the diarrhea on Aaron's skin? A) Apply a moisture-repellent ointment on intact skin areas. B) Rinse ulcer areas with an alcohol-based solution C) Position a plastic-line pad under the buttocks D) Apply moist heat to the ear following exposure to feces.
A) Apply a moisture-repellent ointment on intact skin areas. Rationale: After the skin is cleaned and dried, a moisture-repellent ointment should be applied to protect and moisturie the skin. Fecal toxins are damaging to tissue, and excessive moisture causes skin maceration and damage.
The home care nurse teaches Aaron about dietary measures to promote wound healing and emphasizes the need for extra protein. The nurse encourages him to select which breakfast items to provide a good source of protein? A) Whole wheat toast with butter B) Bagels and cream cheese C) Oatmeal and a banana D) Eggs and orange juice
D) Eggs and orange juice Rationale: Eggs are a good source of protein, iron, ad zinc, which are all important for wound healing. Citrus juices, such as OJ are goos source of Vitamin C, which is also important for wound healing.
The nurse observes that the reddish area round, 3 cm diameter, and is directly over the client's sacrum. The skin is intact. In addition to measuring the length of the time the redness lasts, which assessment measure should the nurse perform? (select all that apply). A) Apply light pressure to the area with the fingertips. B) Measure the diameter of the redness. B) Observe for wound approximation. C) Obtain a wound culture D) Gently lift a fold of skin.
A) Apply light pressure to the area with the fingertips. Rationale: The RN applies light pressure with the fingertips to asses for blanching. This is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairment. B)Measure the diameter of the redness. Rationale: the area of redness should be measured to evaluate progression or healing.
Following wound irrigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing? A) Mechanically debride the tissue B) Reduce local tissue macertion C) Prevent bacterial growth D) Preserve granulation tissue
A) Mechanically debride the tissue Rationale: Moistened gauze is placed on the wound and allowed to dry. It then adheres to the wound tissue and debrides necrotic or infected tissue as it is removed.
It is most important to include this group in which aspect of Aaron's overall care? A) Reviewing class notes and studying for exams B) Helping Aaron plan meals to promote wound healing C) Purchasing wound care supplies for Aaron D) Reminiscing about life when they were all younger
A) Reviewing class notes and studying for exams Rationale: The young adult is developmentally involved in establishing intimacy and working toward furture goals. In addition, studying with his peers will help maintain a sense of normalcy for Aaron. Other tasks can easily be performed by other groups, such as family members. This task can be performed by his peers.
The home care nurse observes that Aaron's ulcer is red, with obvious granulation tissue filling in the ulcer crater. What teaching should the nurse provide? A) Another round of antibiotic therapy will probably be needed B) Hydrocolloid dressings should be continued over the ulcer C) Debridement of the pressure ulcer must be restarted D) The pressure ulcer should now be kept ope to the air
B) Hydrocolloid dressings should be continued over the ulcer Rationale: The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid dressing.
No evidence of drug toxicity is found. Aaron's next BP is within normal limits for him and he has no further episodes of diarrhea. The wound eschar has all been removed, and there is no further drainage. A hydrocolloid dressing is placed over the wound, and Aaron is discharged. Aaron will complete the 2-week antibiotic treatment at home. The home care nurse visits Aaron a week after discharge to assess the wound. The nurse reviews symptoms of pressure ulcers with Aaron as well as when to call the healthcare provider. Aaron yells the nurse and says, "I don't need a nurse to tell me that I will spend the rest of my life in and out of hospitals!" What initial action should the nurse take? A) Confront Aaron about his rude and unacceptable behavior and attitude B) Offer Aaron the opportunity to discuss his feelings of anger and hopelessness C) Ask Aaron's parents to calm him so the nursing assessment can be completed D) Reassure Aaron that he will not need to spend the rest of his life in and out of hospitals
B) Offer Aaron the opportunity to discuss his feelings of anger and hopelessness Rationale: Using TC, the RN can provide the opportunity for Aaron to deal with his concerns.
Before pouring the suspension, the nurse determines that the medication and dose on the bottle's label are correct as prescribed, but the client name listed on the bottle is incorrect. Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy? A) Healthcare provider B) Pharmacist C) Client D) Charge nurse
B) Pharmacist Rationale: incorrectly labeled medications are the responsibility of the pharmacist.
The nurse observes that the sacral ulcer is open, has a crater-like appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. Aaron is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. What documentation best describes the drainage from Aaron's wound? A) Infectious B) Purulent C) Serous D) Sangineous
B) Purulent Rationale: Purulent refers to something that contains or produces pus. Pus is an indication that an infection is likely.
When the medication bottle is properly relabeled, the nurse mixes the suspension prior to pouring it. Which technique should the nurse use to mix the linezolid? A) Shake gently for 60 seconds B) Turn the bottle upside down 3 to 5 times C) Shake vigorously until mixed D) Stir medicine after pouring it into the medication measuring cups
B) Turn the bottle upside down 3 to 5 times Rationale: this method mixes the suspension according to manufactures specifications. Linezolid should never be shaken.
Aaron states, "I'm sorry I yelled at you, but I'm so discouraged about this bed sore and the infection." How should the nurse respond to Aaron's statement? A) "You had an infected pressure ulcer, not a bed sore." B) " You can't allow yourself to become discouraged about this." C) "You are trying to cope with a lot of concerns right now." D) "You don't need to worry, this infection is almost resolved."
C) "You are trying to cope with a lot of concerns right now." Rationale: The response acknowledges the client's experience and encourages further insight and verbalization by the client.
The nurse identifies that Aaron has developed a Stage I pressure ulcer. The nurse is concerned that Aaron may have other pressure ulcers. Which areas are most important for the nurse to observe for additional pressure ulcers? A) Distal tips of the toes. B) Lower abdominal folds C) Heels and ankles D) Thighs and calves
C) Heels and ankles Rationale: pressure ulcers typically occur over bony prominences, such as the heels, and sacral area. While bony prominences are the most common sites for pressure ulcer development. the RN should perfom a complete skin assessment.
The nurse identifies a priority problem for Aaron's plan of care as "Impaired skin integrity". What etiology should the nurse identify? A) Noncompliance with turning schedule B) Poor nutritional intake C) Impaired physical mobility D) Impaired adjustment
C) Impaired physical mobility Rationale: Since Aaron is paraplegic, he is impaired physical mobility, a major factor that contributes to pressure ulcer development.
The nurse correctly uses which technique when pouring the suspension? A) Hold the medication bottle up to eye level B) Hold the medication cup up to eye level C) Place the medication cup on a flat surface at eye level D) Place the medication bottle on a flat surface at eye level
C) Place the medication cup on a flat surface at eye level Rationale: To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.
The nurse suspects that Aaron's wound has developed a sinus tract, or tunneling. What equipment will the nurse use to assess the length of the tract? A) Sterile gloves and lubricant B) sterile tape measure C) Sterile cotton-tipped applicator D) Sterile irrigation tray with syringe
C) Sterile cotton-tipped applicator Rationale: A sinus tract is an extention of the wound under the skin, and it is best assessed by gentle insertion of sterile cotton-tipped applicator to determine the location and length of the tunneling.
At the end of the appointment, the nurse provides client teaching about measures to promote healing and prevent further tissue destruction. To provide pressure relief at night, the nurse teaches Aaron to sleep in which position? A) Supine with the head of the bed elevated? B) Supine with a foam wedge between the knees. C) Thirty-degree lateral inclined position D) Full side-lying position supported with pillows.
C) Thirty-degree lateral inclined position Rationale: this position best reduces pressure on bony prominences where pressure ulcers frequently develop. Pillows and foam wedges may be used for support and protection in this position.
After assessing for sinus tracts, the nurse irrigates the wound as prescribed with normal saline. Which irrigation technique is best? A) Pour the saline directly onto the wound from the bottle. B) Moisten a sterile gauze pad and pat the gauze over the wound C) Irrigate as gently as possible using a 60 ml bulb syringe D) Apply steady pressure using a 35 ml syringe and 19-gauge needle
D) Apply steady pressure using a 35 ml syringe and 19-gauge needle Rationale: Using a 35-ml syringe and 19-gauge needle provides 8 pounds per square inch (PSI), which applies adequate pressure to ensure effective irrigation. Safe, effective pressure is between 4 and 15 PSI. More that 15 PSI will drive bacteria in the wound and destroy healthy tissue.
The nurse prepares a written positioning schedule and places it in Aaron's room as a reminder for the UAP assigned to help with Aaron's care. The charge nurse removes the schedule and states that it violates Aaron's privacy. What action should the nurse take? A) Provide verbal instructions about positioning to the UAP and document the instructions in the nurse's notes. B) Ask the charge nurse to assist with verbal communication to all of the staff involved in Aaron's care to ensure continuity of care C) Advise the charge nurse that client confidentiality is secondary to the continuity of care. D) Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.
D) Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights. Rationale: A written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client's room without compromising client confidentiality.
A wound culture indicates that Aaron's wound is infected with MRSA. Wound care prescribed by the healthcare provider includes wound irrigation. Which protective equipment will the nurse use when providing the prescribed wound care? A) Gloves only B) Gloves and gown C) Gloves, gown, goggles D) Gloves, gown, goggles, face mask
D) Gloves, gown, goggles, face mask Rationale: When there is potential for wound drainage and debris to splatter during the irrigation, the RN should be fully protected. The mode of transmission of MRSA include direct contact, as well as contact with infected surfaces.
During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement? A) Apply heat to reduce the inflammation that has occurred at these sites? B) Notify the healthcare provider that the client is retaining excessive fluid C) Reassure the client that no pressure damage is present at these sites. D) Identify these areas as sites where pressure damage has occurred.
D) Identify these areas as sites where pressure damage has occurred. Rationale: Palpable changes in the consistency of the tissue underlying a bony prominence, often described as :spongy" or "beefy," are an indication that pressure damage has occurred. Additional manifestations may include a change in skin temperature and induration.
