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 B

Explanation

A. Thickening of the epidermis: The epidermis tends to thin rather than thicken with aging.
Thinning of the epidermis can lead to increased vulnerability to injury and slower wound healing.
B. Thinning of the epidermis: Thinning of the epidermis is a common age-related change in the skin. This thinning can result in a decreased barrier function, making the skin more susceptible to damage and infection.
C. Oiliness of the skin: Older adults often experience a decrease in oil production, leading to drier skin rather than oilier skin.
D. Increased elasticity of the skin: With aging, the skin tends to lose elasticity, resulting in sagging and wrinkles rather than increased elasticity.

A. Treatment is to continue for 7 days. B. The appearance of the area is to be documented. C. The procedure is performed with clean technique. D. Room temperature normal saline is prescribed.

Correct Answer is D

Explanation

A. Treatment is to continue for 7 days: This aspect of the prescription is clear and does not require clarification.
B. The appearance of the area is to be documented: Documenting the appearance of the area is a standard nursing practice and does not require clarification from the physician.
C. The procedure is performed with clean technique: The use of clean technique for the procedure is appropriate for the management of a pressure injury and does not require clarification.
D. Room temperature normal saline is prescribed: This aspect of the prescription may require clarification as the nurse needs to ensure that the prescribed solution matches the intended
treatment. Clarification may be necessary if there are specific preferences or considerations regarding the type or temperature of the saline solution to be used.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older client and educating the student nurse on assessing the skin. The student nurse knows that an older client's skin is most likely to experience which of the following changes with aging?

Correct Answer is B

Explanation

A patient is admitted for treatment for a severe ulcerated pressure injury exhibiting signs of infection. The HCP prescribes open wet dressings to be applied every 6 hours for a period of 30 minutes for one week. For which part of the prescription does the nurse clarify with the physician?

Correct Answer is D

Explanation

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