HESI: Skin Integrity and Rationale

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform?

-Apply light pressure to the area with the fingertips. -Measure the diameter of the redness. (The area of redness should be measured to evaluate progression or healing. The nurse applies light pressure with the fingertips to assess for blanching. Blanching is a normal response that indicates there is no tissue perfusion impairment.)

17. The nurse plans to administer a prescribed dose of linezolid, an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The prescription states, "linezolid suspension 400 mg PO every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." How many mL of medication will the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.)

20

11. To reduce the effects of moisture on the client's skin, which intervention should be implemented?

Apply a moisture-repellent ointment to intact skin areas. (After the skin is cleaned and dried, a moisture-repellent ointment should be applied to protect and moisturize the skin. Fecal toxins are damaging to tissue, and excessive moisture causes skin maceration and damage.)

15. The nurse notifies the healthcare provider of sinus tracts discovered during the assessment and receives a prescription to irrigate the wound with sodium chloride 0.9%. Which irrigation technique is best?

Apply steady pressure using a 35 mL syringe and 19 gauge needle. (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 than 15 PSI will drive bacteria into the wound and destroy healthy tissue.)

18. The prescription states, "linezolid suspension 400 mg PO every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." The nurse is scheduled to administer 20 mL.The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 to 1200 mg. What is the total daily dosage (in mg) that the client will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.)

800

24. After the client receives the first dose of linezolid, the nurse reports to the healthcare provider that a rash and itching develop on his thorax, but he has no respiratory symptoms. Which class of medication should the nurse expect to administer?

An antihistamine, such as diphenhydramine. (An antihistamine should control the itching and rash of this reaction. Rash and itching are identified side effects of linezolid. The nurse should, however, continue to monitor for a more severe allergic response.)

23. Prior to administering the first dose of the antibiotic, the nurse asks the client about any drug allergies. The nurse explains to the client that this precaution reduces the risk for what potential problem?

Anaphylactic reaction. (An anaphylactic reaction is a severe allergic response that can be life threatening.)

12. The nurse prepares a written positioning schedule and places it in the client's room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with the client's care. The charge nurse removes the schedule and states that it violates the client's privacy. What action should the nurse take?

Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights. (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.)

13. A wound culture indicates that the client's wound is infected with methicillin-resistant Staphylococcus aureus (MRSA). After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client?

Contact precautions. (The client should be cared for using contact precautions when there is potential for wound drainage and debris to splatter during care. The mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces.)

30. The home care nurse teaches the client 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?

Eggs and orange juice. (Eggs are a good source of protein, iron, and zinc, which are all important for wound healing. Citrus juices, such as orange juice, are a good source of vitamin C, which is also important for wound healing.)

8. Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take?

Encourage them to continue to use this device in their wheelchair at all times. (These cushions help redistribute weight so that it is not all on the ischium. The client should also be instructed to shift weight frequently.)

27. The client apologizes to the nurse and expresses how discouraged they are about the bed sore and the infection. Which nursing response best promotes effective communication?

Help the client identify the concerns he is trying to cope with at this time. (This response acknowledges the client's experience and encourages further insight and verbalization by the client.)

31. The home care nurse observes that the client's ulcer is red, with obvious granulation tissue filling in the ulcer crater. What teaching should the nurse provide?

Hydrocolloid dressings should be continued over the ulcer. (The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid dressing.)

4. 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?

Identify these areas as sites where pressure damage has occurred. (Palpable changes in the consistency of the tissue underlying a bony prominence, often described as "spongy," is an indication that pressure damage has occurred. Additional manifestations may include a change in skin temperature and induration.)

5. The nurse identifies a priority problem for the client's plan of care as "impaired skin integrity." Which etiology identified by the nurse is accurate?

Impaired physical mobility. (Since the client is paraplegic, they have impaired physical mobility, a major factor that contributes to pressure ulcer development.)

3. Which areas are most important for the nurse to observe for additional pressure ulcers?

Ischial tuberosities. Pressure ulcers typically occur over bony prominences, such as the heels, ankles, ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial tuberosities at greater risk for breakdown. While bony prominences are the most common sites for pressure ulcer development, the nurse should perform a complete skin assessment.

16. Following wound irrigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing?

Mechanically debride the tissue. (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.)

20. 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?

Mix according to directions. (Instructions should be to turn 2-3 times, avoid shaking, according to manufacturer's specifications. Linezolid should never be shaken.)

26. No evidence of drug toxicity is found. The client's next BP is within normal limits, and experiences no further episodes of diarrhea. The wound eschar has been removed, and there is no further drainage. A hydrocolloid dressing is placed over the wound, and the client is discharged. The client will complete the 2-week antibiotic treatment at home. The home care nurse visits the client a week after discharge to assess the wound. The nurse reviews symptoms of pressure ulcers with the client, as well as when to call the HCP. The client yells at the nurse and says that they do not need a nurse to tell them that they will spend the rest of their life in and out of hospitals. What initial action should the nurse take?

Offer the client the opportunity to discuss their feelings of anger. (Using therapeutic communication techniques, the nurse can provide the opportunity for the client to deal with his concerns.)

25. The client has been receiving antibiotic therapy for several days. The client has a mild elevation in blood pressure and a 2 × 2 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 hepatoxicity related to antibiotic use. Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity?

Peak and trough. (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 has in the bloodstream. If the trough is greater than the acceptable limit for the drug, the next dose should be withheld and the blood level rechecked 6 hours later.)

19. 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?

Pharmacist (Incorrectly labeled medications are the responsibility of the pharmacist.)

21. The nurse correctly uses which technique when pouring the suspension?

Place the medication cup on a flat surface at eye level. (To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.)

22. The nurse monitors lab values and assesses for adverse effects during the course of the client's treatment with linezolid. During the course of antibiotic treatment with linezolid, which of the client's serum laboratory values requires intervention by the nurse?

Platelet count (100 x 103/mcL (100 X 109 /L) (This medication has been shown to decrease platelet count. Normal platelet count is 130-400 x 103/mcL (130-400 X 109 /L).)

10. A month later, the client arrives in the emergency department at the local hospital and reports having had the flu and has spent most of their time in bed for the last several days. The client has been experiencing vomiting and diarrhea. 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. The client is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. How should the nurse describe the drainage in documenting the wound?

Purulent (Purulent refers to something that contains or produces pus. Pus is an indication that an infection is likely.)

2. The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document?

Reactive hyperemia. (Reactive hyperemia occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than 1 hour and the surrounding tissue does not blanch.)

29. It is most important to include this group in which aspect of the client's overall care?

Reviewing class notes and studying for exams. (The young adult is developmentally involved in establishing intimacy and working toward future goals. In addition, studying with his peers will help maintain a sense of normalcy for the client. Other tasks can easily be performed by other groups, such as family members. This task can best be performed by his peers.)

14. The nurse suspects that the client's wound has developed a sinus tract, or tunneling. Which equipment will the nurse use to assess the length of the tract?

Sterile cotton-tipped applicator. (A sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the location and length of the tunneling. Once length is noted with applicator, then use tape measure to document exact length.)

6. After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal should the nurse include in the client's plan of care?

The client's skin will remain intact without deterioration. (A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.)

28. Considering the client's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group?

The clients girlfriend and his two best male friends from the college. (As a young adult, the clients primary developmental task, according to the theorist Erikson, is to develop intimacy. The nurse should emphasize interaction with a small group of intimate friends to support this developmental task.)

7. At the end of the appointment, the nurse provides client teaching about measures to promote healing and to prevent further tissue destruction. To provide pressure relief at night, the nurse teaches the client to sleep in which position?

Thirty-degree lateral inclined position. (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.)

9. The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer?

Transparent film dressing. (This type of dressing allows for visualization of the area and protects it from shear.)