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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administering analgesic medications: Analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help alleviate pain associated with impaired skin integrity by reducing inflammation and blocking pain signals.
B. Performing gentle massage on the affected area: While massage can sometimes provide relief for certain types of pain, it may not be appropriate for all types of impaired skin integrity and could potentially exacerbate the condition or cause further damage.
C. Applying a heating pad to the affected area: Heat therapy may be contraindicated for certain types of impaired skin integrity, as it can increase inflammation and worsen pain. It is not
typically recommended as a primary intervention for managing pain in this context.
D. Using topical antibiotics on the affected area: Topical antibiotics are used to treat or prevent infections but are not primarily indicated for pain management associated with impaired skin
integrity.
Correct Answer is D
Explanation
A. Povidone-iodine: Povidone-iodine is an antiseptic agent used for skin disinfection but is not recommended for routine hand hygiene, especially in cases of Clostridium difficile infection.
B. Alcohol-based antiseptic: While alcohol-based hand sanitizers are effective for most routine hand hygiene situations, they may not be sufficient for removing spores of Clostridium difficile. Soap and water are preferred for hand hygiene in cases of C. difficile infection.
C. Chlorhexidine: Chlorhexidine is an antiseptic agent commonly used for skin disinfection, but like alcohol-based hand sanitizers, it may not effectively remove C. difficile spores. Soap and water are preferred.
D. Soap and water: Soap and water are recommended for hand hygiene in cases of Clostridium difficile infection because mechanical friction from hand washing helps physically remove
spores from the hands.
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