Exam 4 PrepU Questions

Which change in the integumentary system is associated with normal aging? A. The dermis becomes highly vascular and assists in the regulation of body temperature. B. The outer layer of skin is replaced with new cells every 3 days. C. Collagen becomes elastic and strong. D. Subcutaneous fat and extracellular water decrease.

D. Subcutaneous fat and extracellular water decrease. With age, there is a decreased amount of subcutaneous fat, muscle laxity, degeneration of elastic fibers, and collagen stiffening. The outer layer of skin is almost completely replaced every 3 to 4 weeks. The vascular supply diminishes with age. Collagen thins and diminishes with age.

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers? A. a client who has a decreased serum albumin level B. a client with an elevated white blood cell count C. a client with an indwelling urinary catheter D. a client who ambulates 4 times a day

A. a client who has a decreased serum albumin level Risk factors for the development of pressure ulcers include poor nutrition, indicated by a decreased serum albumin level. According to the Guidelines for Pressure Ulcers published by the Agency for Healthcare Research and Quality, other risk factors include immobility, incontinence, and decreased sensation. A client who does not ambulate often can be repositioned frequently to prevent pressure ulcers. Having an indwelling urinary catheter does not normally increase the risk of developing a pressure ulcer unless pressure from the tubing impinges on urethral or other tissue. An elevated white blood cell count does not place a client at risk for pressure ulcers.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma? A. "The stoma should remain swollen distal to the abdomen." B. "A burning sensation under the stoma faceplate is normal." C. "At first, the stoma may bleed slightly when touched." D. "The stoma should appear dark and have a bluish hue."

C. "At first, the stoma may bleed slightly when touched." The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

An older adult who is to be on bed rest has become incontinent of urine. To prevent pressure ulcers, the nurse should do which tasks? Select all that apply. A. Use a sanitary napkin to absorb urine. B. Anchor a Foley catheter. C. Have client wear incontinence briefs. D. Institute a turning schedule. E.Inspect the groin for wetness.

C. Have client wear incontinence briefs. D. Institute a turning schedule. E.Inspect the groin for wetness. Sanitary napkins are not designed to contain/absorb urine. Anchoring a Foley catheter increases the risk for infection.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? A. The dressing should be allowed to dry out before removal. B. A plastic sheet-type dressing should cover the wet dressing. C. The dressing should keep the wound moist. D. The wet-to-damp dressing should be tightly packed into the wound.

C. The dressing should keep the wound moist. A wet-to-damp saline dressing should always keep the wound moist. Tight or dry packing can cause tissue damage and pain. A dry gauze dressing — not a plastic sheet-type dressing — should cover the wet dressing.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? A. Call the surgeon to come to the client's room immediately. B. Press the emergency alarm to call the resuscitation team. C. Have all visitors and family leave the room. D. Cover the abdominal organs with sterile dressings moistened with sterile normal saline.

D. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.