Tissue Integrity Flashcards
(25 cards)
a nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client’s surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?
Fistula
Evisceration
Hematoma
Dehiscence
Dehiscence
a nurse is assisting with the care of a 6 month old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?
Premature wrinkling
Skin tears
Dermatitis
Cellulitis
Dermatitis
RATIONALE:
The nurse should monitor the infant for dermatitis. During infancy and early childhood when the skin is immature, dermatitis develops when the skin is exposed to urine and feces. The infant will be at an even greater risk for dermatitis due to the frequency of stools.
a nurse is reinforcing teaching with a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
“The epidermis pads internal organs and structures.”
“The skin assists in the regulation of body temperature.”
“The subcutaneous layer of the skin contains cells that contribute to skin and hair color.”
“The skin is strongest during early childhood.”
“The skin assists in the regulation of body temperature.”
a nurse is assisting with the care of a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?
A client who is NPO for surgery and is receiving IV fluids.
A client who has a lower extremity fracture and uses the overhead bed trapeze to move.
A client who is incontinent and is taking a prescribed diuretic.
A client who has lung cancer and will be receiving their first radiation treatment.
A client who is incontinent and is taking a prescribed diuretic.
a nurse in a dermatology clinic is assisting with the development of a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?
Collagen and elastin fibers increase with age.
The dermis contains blood vessels that help nourish the epidermis.
The skin consists of four distinct layers.
The epidermis contains cells that assist in systemic immune responses.
The dermis contains blood vessels that help nourish the epidermis.
a nurse is reinforcing teaching with a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?
“Pressure injury documentation includes the location, stage, measurements, condition of the wound bed and any drainage present.”
“Drainage from a pressure injury only needs to be documented if a foul odor is present.”
“If the pressure injury is healing as expected, documentation can be completed with every other dressing change.”
“Pressure injuries found on the mucous membranes should be documented as stage 1 pressure injuries.”
“Pressure injury documentation includes the location, stage, measurements, condition of the wound bed and any drainage present.”
a nurse is assisting with the care of a client who has a dime-size stage 1 pressure injury located on the sacrum. Which of the following dressing types should the nurse use?
An alginate dressing
A wet gauze dressing
A hydrogel dressing
A transparent film
A transparent film
RATIONALE:
Due to their reduced ability to absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate.
A nurse is reinforcing teaching with an AP about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?
“The layers of the skin become detached with age.”
“The skin of older adults is thinner and has less subcutaneous padding over bony prominences.”
“Older adult clients have more moisture in the skin placing them at risk for maceration.”
“Skin changes cause the synthesis of vitamin B to decrease with age.”
“The skin of older adults is thinner and has less subcutaneous padding over bony prominences.”
a nurse is observing an AP care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?
The AP places the client in high-Fowler’s position.
The AP places pillows under the client’s lower extremities.
The AP feeds the client 80% of each meal.
The AP cleans and dries the client’s perineum after each episode of incontinence.
The AP places the client in high-Fowler’s position.
RATIONALE:
Placing the client in the high-Fowler’s position increases the risk for shearing and alterations in skin integrity. Shearing occurs when clients are sitting or lying on an incline, such as sitting in the high-Fowler’s position in bed. As the client sits, gravity pulls deeper tissues like fat and muscle downward while the top layers of the skin are still in contact with the surface. Shearing results in stretching and trauma to the blood and lymphatic vessels.
A nurse is reinforcing teaching with a client about staple removal. Which of the following statements should the nurse make?
“Your staples will dissolve in about 4 weeks.”
“You will need to be placed under general anesthesia for the staples to be removed.”
“Staples are unlikely to become embedded in the skin making removal simple.”
“Your staples will be removed in about 2 weeks.”
“Your staples will be removed in about 2 weeks.
a nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?
Obtain the culture using a clean cotton applicator.
Clean the wound with 0.9% sodium chloride.
Collect drainage from the area surrounding the wound.
Place the applicator in a dry vial until cultures are complete.
Clean the wound with 0.9% sodium chloride.
a nurse is reinforcing teaching with a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instruction by the nurse is relating to preventing skin breakdown?
“You should shift your weight off your buttocks at intervals throughout the day.”
“You should be sure your legs are placed on the floor prior to transferring.”
“Position yourself in the back of the wheelchair after transferring.”
“Lock your brakes when you are sitting in the wheelchair.”
“You should shift your weight off your buttocks at intervals throughout the day.”
a nurse is assisting with the care of a client who has sustain a gunshot wound to the abdomen and is 6hr postop. the nurse notices protrusion of the clients organs from the incision sit and calls for help. Which of the following actions should the nurse take?
Ask the client to bear down and cough.
Ask another nurse to bring icepacks to apply to the wound.
Cover the client’s wound with a sterile saline dressing.
Place the client in high-Fowler’s position.
Cover the client’s wound with a sterile saline dressing.
a nurse in a outpatient clinic is collecting data from a client who is 7 days postop. Which of the following findings should the nurse expect to find at the clients incision site?
A red incision site with a small amount of exudate
A bright pink incision site that is absent of exudate
A pale pink incision site with moderate amounts of exudate
A white to silver incision site absent of exudate
A bright pink incision site that is absent of exudate
a nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding for the information?
“I should expect a small separation along the incision line.”
“If I feel like something popped, I should sit up in bed.”
“I should report pain at my wound site.”
“Recurrent vomiting is expected after surgery.”
“I should report pain at my wound site.”
a nurse is assisting with the care of a client who has a deep foot wound with minimal exudate and necrotized tissue. Which of the following dressing types should the nurse anticipate a prescription for to cover the wound?
Hydrofiber
Alginate
Hydrogel
Transparent film
Hydrogel
a nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?
Hypertension
Increased blood glucose
Decreased WBC count
Increased BUN
Increased blood glucose
a nurse is assisting with discharge teaching for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should the client’s caregiver to prevent further skin breakdown?
Flex the client’s knees while in bed.
Do not use pillows to support extremities.
Be sure to keep the skin moist.
Provide a firm mattress for the client.
Flex the client’s knees while in bed.
a nurse is collecting data from a client who has a stage 3 pressure injury on the coccyx. Which of the following alterations in tissue integrity should the nurse expect to find?
Partial-thickness skin loss with a pink and moist wound bed
An area of non-blanchable erythema
Full-thickness skin loss with visible adipose tissue
Full-thickness skin loss with visible muscle and bone
Full-thickness skin loss with visible adipose tissue
a nurse is reinforcing teaching with a newly licensed nurse about would healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?
“This type of healing begins in the wound bed with the generation of granulation tissue.”
“This type of healing carries a lower risk of infection than others.”
“These wounds heal faster than those that heal by other processes.”
“These wounds require a dry wound bed in order for healing to occur.”
“This type of healing begins in the wound bed with the generation of granulation tissue.”
a nurse is reinforcing teaching with a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?
“I should avoid meat products.”
“I should consume a diet high in carbohydrates.”
“I should include fruit and vegetables with every meal.”
“I should increase my protein intake.”
“I should increase my protein intake.”
RATIONALE:
Foods high in protein are essential for wound healing and tissue strengthening, as are foods with omega-3 and omega-6 fatty acids and foods with vitamins A and C.
a nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?
A client who has a Braden Scale score of 9
A client who has a Braden Scale score of 23
A client who has a Braden Scale score of 12
A client who has a Braden Scale score of 15
A client who has a Braden Scale score of 9
a nurse is assisting with the care of a client who has a portable wound bulb suction device and notes that the drainage bulb is 3/4 full. Which of the following actions should the nurse take?
Kink the tubing to prevent further drainage.
Empty and measure the drainage.
Decrease the drainage suction force.
Place the bulb on a flat surface and measure the amount of drainage.
Empty and measure the drainage.
a nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicates an understanding of an alginate dressing?
“The dressing will need to be changed every 24 hours.”
“This type of dressing is used in small wounds with small amounts of drainage.”
“This dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped.”
“This type of dressing will need a secondary dressing for reinforcement.”
“This type of dressing will need a secondary dressing for reinforcement.”
