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. 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.

A. Document the client's history of skin allergies. B. Photograph the lesion for the client's medical record. C. Identify when the client first noticed the lesion. D. Instruct the client on the use of daily sunscreen products.

Correct Answer is C

Explanation

A. Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B. Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C. Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D. Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.

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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 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

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

Which of the following is an example of a reservoir in the chain of infection?

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