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 C

Explanation

A. Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B. Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C. Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D. Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

A. Endogenous Infection B. Systemic Infection C. Exogenous Infection D. Health Care-Associated Infection

Correct Answer is D

Explanation

A. Endogenous Infection: Endogenous infections originate from the client's own microbiota and typically do not involve medical interventions such as urinary catheterization.
B. Systemic Infection: Systemic infections affect the entire body and may not necessarily be related to the urinary tract.
C. Exogenous Infection: Exogenous infections originate from sources outside the client's body.
While the urinary tract infection could be caused by bacteria from the environment, it is more specifically categorized as a healthcare-associated infection (HAI) due to the indwelling urinary catheter being a risk factor.
D. Health Care-Associated Infection: A healthcare-associated infection (HAI) occurs as a result of healthcare interventions and can include infections related to urinary catheterization, surgery, or other medical procedures.

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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

The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Correct Answer is C

Explanation

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

Correct Answer is D

Explanation

Which of the following infections would the nurse recognize as being a health care-associated infection?

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