A patient is incontinent the first day after his surgery.
This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:
The patient has to be repositioned for the bed to be changed.
Shearing is more likely from wet sheets.
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
The Correct Answer is C
Choice A rationale:
Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.
Choice B rationale:
While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.
Choice C rationale:
Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.
Choice D rationale:
A wet bed does not exert greater pressure on the patient’s skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Karaya paste is used for ostomy care, not for dressing changes.
Choice B rationale:
Paper tape might not provide the necessary adhesion for frequent dressing changes.
Choice C rationale:
Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.
Choice D rationale:
Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.
Correct Answer is C
Explanation
Choice A rationale:
Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.
Choice B rationale:
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.
Choice C rationale:
Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.
Choice D rationale:
Stage 1 pressure injuries involve non-blanchable erythema of intact skin.
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