Tissue Integrity
A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?
Dermatitis
A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?
Hydrogel
A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?
"I should increase my protein intake."
A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?
"I should report pain at my wound site."
A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?
"Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present."
A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?
"Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."
A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"The skin assists in the regulation of body temperature."
A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?
"The skin of older adults is thinner and has less subcutaneous padding over bony prominences."
A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?
"This type of dressing will need a secondary dressing for reinforcement."
A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?
"This type of healing begins in the wound bed with the generation of granulation tissue."
A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?
"You should shift your weight off your buttocks at intervals throughout the day."
A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?
"Your staples will be removed in about 2 weeks."
A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?
A bright pink incision site that is absent of exudate
A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?
A client who has a Braden Scale score of 9
A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?
A client who is incontinent and is taking a prescribed diuretic.
A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?
A transparent film
A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?
Clean the wound with 0.9% sodium chloride.
A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and calls for help. Which of the following actions should the nurse take?
Cover the client's wound with a sterile saline dressing.
A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?
Dehiscence
A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?
Empty and measure the drainage.
A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?
Flex the client's knees while in bed.
A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?
Increased blood glucose
A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?
The AP places the client in high-Fowler's position.
A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?
The dermis contains blood vessels that help nourish the epidermis.
A nurse is planning care for an older adult client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?
Tilt the client on their side at 30°.