Which of the following signs is most indicative of impaired skin integrity?

Skin feeling warm to the touch

Presence of a wound with partial thickness skin loss

Dry skin with no visible lesions

Slight redness of the skin after applying pressure

Answer and Explanation

The Correct Answer is B

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D"]

Explanation

A. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs independently.

B. IV fluids require a provider’s order.

C. Collaboration is not an independent intervention.

D. Independent nursing interventions do not require a provider’s order. Nurses can assist with ADLs and assess pain independently.

E. Administering prescribed medication requires an order.

A. Turn and reposition the patient every 2 hours. B. Assess the patient's skin condition. C. Apply hydrocolloid dressing to the pressure injury. D. Change pressure injury dressings every shift.

Correct Answer is A

Explanation

A. This is a routine, non-clinical task that does not require nursing judgment and can be safely delegated to NAP to help prevent pressure injuries.

B. Assessment is a nursing responsibility and cannot be delegated to NAP. Only a licensed nurse can evaluate the skin’s condition.

C. Wound care requires nursing expertise to ensure proper application and monitoring for signs of infection.

D. Dressing changes require clinical assessment and are outside the scope of NAP practice.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following signs is most indicative of impaired skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care to a patient in an acute care facility. Which of the following are examples of independent nursing interventions? (Select All that Apply.)

Correct Answer is ["A","D"]

Explanation

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?

Correct Answer is A

Explanation

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?