Which of the following assessments should be performed to monitor for impaired tissue integrity?

Pupil size and reaction

Heart rate and blood pressure

Respiratory rate and oxygen saturation

Skin turgor and moisture

Answer and Explanation

The Correct Answer is D

A.   Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B.   Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C.   Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D.   Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.

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Correct Answer is D

Explanation

A. "A culture identifies an antibiotic's effect on a pathogen.": Cultures do not determine the effect of antibiotics on pathogens; they identify the presence of pathogens and their susceptibility to antibiotics.
B. "A culture determines the appropriate medication dose.": Cultures do not determine medication doses; they identify pathogens and guide antibiotic selection based on susceptibility testing.
C. "A culture measures antibiotic levels.": Cultures do not measure antibiotic levels; they identify pathogens and their susceptibility to antibiotics.
D. "A culture identifies the presence of pathogens.": This is the correct explanation. A wound culture is performed to identify any microorganisms present in the wound, such as bacteria or fungi, which helps guide appropriate treatment.

A. A client who has swelling, tenderness, and purulent drainage around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling, tenderness, and purulent drainage around the wound are classic signs of a wound infection. Swelling and tenderness indicate inflammation, while purulent drainage (pus) suggests the presence of infection.
B. Urticaria and itching around the wound are more indicative of an allergic reaction or hypersensitivity rather than a wound infection.
C. Serosanguineous drainage (clear to blood-tinged fluid) is a normal finding in the early stages of wound healing and does not necessarily indicate infection.
D. Brown crusting over the wound may indicate the formation of an eschar, which can occur in wounds undergoing healing, particularly in wounds with necrotic tissue. It is not necessarily indicative of infection unless accompanied by other signs such as erythema, warmth, or purulent drainage.

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Which of the following assessments should be performed to monitor for impaired tissue integrity?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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