Tissue Integrity Practice Questions

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? A.) Reddened perineal skin B.) Absence of discharge C.) Presence of smegma D.) Moist perineal skin

A.) Reddened perineal skin

An 81-year-old resident of an elder care facility is immobile and has been restricted to bed for the past 6 weeks. The health care provider recently discovered a decubitus injury on the left buttock. Which etiology is most likely? A.) ischemia from prolonged pressure B.) opportunistic viral infection C.) bacterial infection from improper bathing D.) laceration due to immobility

A.) ischemia from prolonged pressure

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? A.) Sedimentation rate B.) Prothrombin time C.) Serum glucose D.) Serum albumin

D.) Serum albumin

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A.) administering pain medications on a PRN and regular basis B.) preventing scar formation so it does not limit joint movement C.) telling the client that a mild fever is a normal response D.) assisting the client in moving to prevent strain on the suture line

D.) assisting the client in moving to prevent strain on the suture line

Following an injury resulting in a small cut from a knife, the first cells to go to the area of the cut would be the: A.) Erythrocytes B.) Neutrophils C.) Basophils D.) Albumin

B.) Neutrophils

A nursing diagnosis of Risk for impaired tissue integrity would be most appropriate for which client? A.) client with endometriosis B.) client having reconstructive breast surgery C.) client with a vaginal packing in place D.) client taking oral contraceptives

B.) client having reconstructive breast surgery

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A.) large numbers of red blood cells B.) white blood cells, debris, bacteria C.) mixture of serum and red blood cells D.) clear, watery blood

B.) white blood cells, debris, bacteria

While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? A.) "Altered skin integrity related to decreased mobility." B.) "Possible pressure injury observed over client's coccyx region." C.) "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm." D.) "Reddened area noted on skin surface superficial to client's coccyx."

C.) "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A.) administering pain medications on a PRN and regular basis B.) telling the client that a mild fever is a normal response C.) assisting the client in moving to prevent strain on the suture line D.) preventing scar formation so it does not limit joint movement

C.) assisting the client in moving to prevent strain on the suture line