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. Potassium: Potassium levels are not typically used to diagnose infection. Elevated potassium levels may indicate other health conditions such as kidney dysfunction.
B. BUN (Blood Urea Nitrogen): BUN levels assess kidney function and are not directly related to the presence of infection.
C. WBC count (White Blood Cell count): An elevation in the WBC count, specifically the neutrophil count (neutrophilia), is indicative of the body's response to infection or inflammation.
D. RBC count (Red Blood Cell count): RBC count is not typically used to diagnose infection.
Elevated RBC count may indicate conditions such as dehydration or polycythemia.

A. Thickening of the epidermis. B. Thinning of the epidermis. C. Oiliness of the skin. D. Increased elasticity of the skin.

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.

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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

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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