MS Lesson 2 Tissue Integrity
The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)
"Can you easily change your position?" "Do you have sensitivity to heat or cold?" "How often do you need to use the toilet?" "Have you ever fallen?"
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?
"I am ready for my bath and linen change right now since this is awful."
A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching?
"I don't bother with sunscreen on overcast days."
A patient with atopic dermatitis has a new prescription for tacrolimus (Protopic). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed?
"If the medication burns when I apply it, I will wipe it off and call the doctor."
A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate?
"It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."
A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" The nurse's most helpful response would be which of the following?
"That is not correct. Melanoma is more commonly found on the torso or the lower legs of women."
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
20
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
23
The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one?
Apply sterile gloves Assess wound and surrounding skin. Moisten gauze with prescribed solution. Gently wring out excess solution and unfold. Loosely pack until all wound surfaces are in contact with gauze. Cover and secure topper dressing.
To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following?
Apply sunscreen 30 minutes prior to exposure.
The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel?
Applying an elastic bandage to a medical-surgical patient
When examining a patient's oral cavity, the nurse notes the presence of white lesions that resemble milk curds at the back of the throat. Which question by the nurse is appropriate at this time?
Are you taking any medications at present?
Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications?
Ask about fatigue or feelings of malaise.
The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)
Cover exposed wounds Assess the condition of current dressings. Inspect the skin for abrasions and edema. Assess the skin at underlying areas for circulatory impairment.
A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on?
Decreasing pruritus
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
Determine the patient's risk factors.
After a patient with a squamous cell carcinoma (SCC) has a Mohs procedure in the dermatology clinic, which nursing action will be included in the postoperative plan of care?
Educate about use of cold packs to reduce bruising and swelling.
The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)
Hemostasis Maturation Inflammatory Proliferative
The health care provider diagnoses impetigo for a patient who has crusty vesicopustular lesions on the lower face. Which topic will be included in the teaching plan for this patient?
How to clean the infected areas with soap and water
A patient's 6 ´ 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse use for wound care?
Hydrocolloid dressing (DuoDerm)
The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)
Hyperemia Induration Blanching Temperature of skin
A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage
III
The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?
Ineffective peripheral tissue perfusion
The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question?
Irrigate with Dakin's solution.
A patient is diagnosed with basal cell carcinoma (BCC) of the face. Which information should be included in patient teaching?
Minimizing sun exposure will reduce risk for future BCC.
When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider?
New 5-cm separation of the proximal wound edges
The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.)
Place moist sterile gauze over the site. Contact surgical team Monitor for shock
The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility?
Provide analgesic medication as ordered.
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Provide analgesic medications as ordered.
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
Report by patient that something has given way
A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention?
Scarring that may be severe
The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)
Skin is intact with no redness or swelling. Nonblanchable erythema is absent. No injuries to the skin and tissues are evident. Granulation tissue is present.
A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate
Streptococcus pyogenes.
The nurse notes darker skin pigmentation in the skinfolds of a patient who has a body mass index of 40 kg/m2. Which action should the nurse take?
Teach the patient about the risk for type 2 diabetes.
The charge nurse observes a new graduate performing a dressing change on a stage II left heel pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care?
The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the nose. Which information will the nurse include in the patient teaching plan?
The nose will develop painful, eroded areas that will take weeks before completely healing
After the nurse has finished teaching a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg, which patient action indicates that more teaching is needed?
The patient applies a thick layer of the cream to the affected skin.
. When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
The patient takes corticosteroids daily for rheumatoid arthritis.
Through interviewing a patient who has a history of contact dermatitis, the nurse obtains this information about over-the-counter (OTC) medication use. Which finding indicates a need for patient teaching?
The patient uses Neosporin ointment on minor cuts or abrasions.
After the nurse determines that a patient has the following risk factors for melanoma, which risk factor should be the focus of patient teaching related to prevention?
The patient uses a tanning booth throughout the winter.
The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first?
The patient who has been receiving immunosuppressant medications and has a temperature of 102° F.
Which of these four patients should the medical-surgical unit charge nurse assign to an LPN team member?
The patient who requires a hydrocolloid dressing change for a Stage III sacral ulcer.
The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. Which is the best goal for this patient?
The patient will remain free of odorous or purulent drainage from the wound.
The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
The site has a mass, bluish in color.
The nurse is assessing a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which of the following assessment data is a priority?
The skin around the incision is pale and cold when palpated.
The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?
air-fluidized
A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?
albumin
The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?
apply ice
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. To minimize complications from this procedure, the nurse plans to
ave the patient use protective eyewear while receiving PUVA.
A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to
change the patient's position at least every 2 hours.
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
debride the wound
The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?
decreased LOC
The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult?
dietitican
he nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
document
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate?
elevate ankle above the heart
The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take?
explain the procedure
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
fecal incontinence
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
full-thickness wound repair
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?
granulation
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
halogen light
The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record?
healing stage III
The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
impaired skin integrity
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
inspect the wound for bleeding
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
less than 2 hours
A diabetic patient is admitted for a laparotomy and possible release of adhesions. When planning interventions to promote wound healing, the nurse's highest priority will be
maintaining the patient's blood glucose within a normal range.
A older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to check himself or herself?
monitor spots for color change
A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to
obtain wound culture
When examining a patient's scalp, the nurse suspects the presence of pediculosis on finding
papular, wheal-like lesions with white deposits on the hair shaft.
A patient in the dermatology clinic has a small, slow-growing papule with ulceration and a depression in the center of the lesion on the right cheek. The nurse will anticipate the need to
prepare pt for biopsy
The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer?
pressure
The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?
pressure points
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?
primary intention
A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?
protection for UV exposure
The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian?
protein
A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?
pt with clean stage I
A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?
pulse ox assessment
A patient with a systemic bacterial infection has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for
rising body temperature
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?
secondary intention
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
stage II
The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use when teaching the patient the reason for the binder?
supports the abdomen
A patient with an enlarging, irregular mole that is 6 mm in diameter is scheduled for outpatient treatment. The nurse should plan on teaching the patient about
surgical excision
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. Which finding by the nurse indicates a possible adverse effect of the medication?
thinning of affected skin
The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?
tilize a transfer device to lift the patient.
The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient; the nursing assistant understands the instruction when she agrees to
turn the patient at least every 2 hours
The nurse will plan to use wet-to-dry dressings when providing care for a patient with a a pressure ulcer with pink granulation tissue.
wound with purulent drainage and dry brown areas.
A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a
yellow wound
A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient?
Apply a thin coat to affected areas; avoid the face and groin.
Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's stage III sacral pressure ulcer?
Administer the ordered PRN oral opioid 30 minutes before the dressing change.
The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next?
Call the health care provider; a blockage is present in the tubing.
A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate?
Check the patient's oral temperature again in 4 hours.
Which nursing action should the nurse delegate to nursing assistive personnel (NAP) who are assisting with the care of a patient with furunculosis?
Cleaning the skin with antimicrobial soap.
The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?
Cleanse in a direction from the least contaminated area. (I DONT GET THIS ONE)
The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results.
When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. Which action is best for the nurse to take at this time?
Consult with the health care provider about the need for further diagnostic testing.
To decrease the risk for sun damage to the skin, which information should the nurse include when teaching patients?
Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time).
Which action will the nurse take when applying a wet dressing to an inflamed and pruritic area of skin on a patient's ankle?
Use a cool solution to wet the dressing.
Which information should the nurse include when teaching a patient who has just received a prescription for sulfamethoxazole and trimethoprim (Septra, Bactrim) to treat a urinary tract infection?
Use a sunscreen with a high SPF when exposed to the sun.
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk?
Use gentle cleansers, and thoroughly dry the skin.
Which information will the nurse include when teaching a 70-year-old patient about skin care?
Use warm water and a moisturizing soap when bathing.
The nurse is caring for a group of patients. Which patient will the nurse see first?
a patient with appendicitis using a heating pad
