ATI Tissue Integrity Assessment

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply). a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin D e. Vitamin K

a, b, c, e

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? a. Kidney beans b. Grilled salmon c. Peanut butter d. Raw spinach

b

Select the 5 findings that can cause delayed wound healing. a. Potassium level b. Pre albumin level c. History of diabetes mellitus d. History of hyperlipidemia e. Wound infection f. Decreased pedal perfusion g. Fasting blood glucose

b, c, d, e, f

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? a. Check the client's vital signs. b. Assess the client's pain level. c. Cover the wound with a moist, sterile gauze dressing. d. Obtain a culture and sensitivity of the wound drainage.

c

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. Document what the nurse believes was the cause of ulcer development. b. Include any relevant statements the client made about the ulcer. c. Document in the client's medical record that she completed an incident report. d. Question the charge nurse about care deficits that might have contributed to the ulcer's development.

b

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? a. Apply a heat lamp twice a day. b. Reposition the client at least every 2 hr. c. Clean the wound with hydrogen peroxide solution. d. Massage reddened areas with dressing changes.

b

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? a. Abrasion b. Contusion c. Laceration d. Puncture

c

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? a. Exposed bone b. Blood filled blisters c. Partial-thickness skin loss. d. Necrotic subcutaneous tissue

d

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? a. Serum albumin 3.2 g/dL b. Hemoglobin to g/al c. WBC count 8,000/mm° d. INR 0.9

a

A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? a. Do not apply heat to the area of irradiation. b. Do not wash the area of irradiation. c. Use an antibiotic ointment to treat skin breakdown. d. Lubricate the skin lubricated with hypoallergenic lotion.

a

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? a. Instruct the client about home disposal of contaminated dressings. b. Schedule a follow-up visit by a home health nurse for dressing changes. c. Provide a dietary list of foods which promote wound healing. d. Establish a follow-up appointment with the client's provider.

b

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply). a. A client who is ambulatory following a cardiac catheterization 4 hr ago. b. A client who has type1 diabetes mellitus and is hyperglycemic. c. A client who has protein calorie malnutrition. d. A client who has right-sided heart failure and 4+ edema to the lower extremities. e. A client who has postoperative delirium.

c, d, e

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following? a. Client lacks the sensory awareness about the need to void. b. Client experiences a strong perceived urge to void. c. Client does not reach the toilet before experiencing voiding. d. Client leaks Urine when coughing or sneezing.

c; Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure iS increased, such as with coughing or sneezing.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? a. Raise the head of the client's bed 15° to 20°. b. Place the client supine with knees bent. c. Assess the client for manifestations of shock. d. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

d

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? a. Protein b. Calcium c. Vitamin B1 d. Vitamin D

d