HESI SKIN INTEGRITY – Flashcards

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? (Select all that apply.)Apply light pressure to the area with the fingertips. Measure the diameter of the redness. Obtain a wound culture. Gently lift a fold of skin Observe for wound approximation.

The sacral area has remained red for 2 hours and does not blanch when tested. How will the nurse document this finding? Excessive pallor. Unusual skin mottling. Dependent sacral rubor. Reactive hyperemia.

Which areas are most important for the nurse to observe for additional pressure ulcers? Distal tips of the toes. Lower abdominal folds. Heels and ankles. Thighs and calves.

What action should the nurse implement? Apply heat to reduce the inflammation that has occurred at these sites. Notify the healthcare provider that the client is retaining excess fluid. Reassure the client that no pressure damage is present at these sites. Identify these areas as sites where pressure damage has occurred.

The nurse identifies a priority problem for Aaron's plan of care as "Impaired skin integrity." What etiology should the nurse identify? Noncompliance with turning schedule. Poor nutritional intake. Impaired physical mobility. Impaired adjustment.

After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal will the nurse include in Aaron's plan of care? Client's skin will remain intact. Client's motor function will be restored. Client teaching will be provided. Impaired skin integrity will not occur.

At the end of the appointment, the nurse provides client teaching about measures to promote healing and prevent further tissue destruction. To provide pressure relief at night, the nurse teaches Aaron to sleep in which position? Supine with the head of the bed elevated. Supine with a foam wedge between the knees. Thirty-degree lateral inclined position. Full side-lying position supported with pillows.

Upon learning that Aaron has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take? Encourage him to continue to use this device in his wheelchair at all times. Recommend that he replace the gel pad with a donut-shaped foam cushion. Advise him to avoid the use of any form of pressure cushion on his wheelchair. Teach him that regular use of skin moisturizer is more important than cushion use.

The nurse teaches Aaron to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer? Transparent film dressing. Aherent film dressing. Gauze dressing. Hydrogel covered with a foam dressing.

A month later, Aaron arrives in the emergency department at the local hospital. He reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that the sacral ulcer is open, has a crater-like appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. Aaron is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. Which documentation best describes the drainage from Aaron's wound? Infectious. Purulent. Serous. Sanguineous.

Which intervention is important to reduce the effect of the diarrhea on Aaron's skin? Apply a moisture-repellent ointment to intact skin areas. Rinse ulcerated areas with an alcohol-based irrigating solution. Position a plastic-lined pad under the buttocks. Apply moist heat to the area following exposure to feces.

Serous,

Sanguineous

Purulent,

Serosanguineous,

A wound culture indicates that Aaron's wound is infected with methicillin-resistant Staphylococcus aureus (MRSA). Wound care prescribed by the healthcare provider includes wound irrigation. Which protective equipment will the nurse use when providing the prescribed wound care? Gloves only. Gloves and gown. Gloves, gown, and goggles. Gloves, gown, goggles, and face mask.

What equipment will the nurse use to assess the length of the tract? Sterile gloves and lubricant. Sterile tape measure. Sterile cotton-tipped applicator. Sterile irrigation tray with syringe.

Which irrigation technique is best? Pour the saline directly onto the wound from the bottle. Moisten a sterile gauze pad and pat the gauze over the wound. Irrigate as gently as possible using a 60-ml bulb syringe. Apply steady pressure using a 35-ml syringe and 19-gauge needle.

Following wound irrigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing? Mechanically debride the tissue. Reduce local tissue macertion. Prevent bacterial growth. Preserve granulation tissue.

What is a sinus tract?

Prior to administering the first dose of the antibiotic, the nurse asks Aaron about any drug allergies. The nurse explains to Aaron that this precaution reduces the risk for what potential problem? Anaphylactic reaction. Idiosyncratic response. Drug tolerance. Resistance to the antibiotic.

After receiving the first dose of Zyvox, Aaron develops a rash and itching on his thorax, but no respiratory symptoms. Which class of medication should the nurse expect to administer? An anticholinergic medication, such as atropine (AtroPen). An adrenergic medication, such as epinephrine (Adrenalin). An antipyretic medication, such as acetaminophen (Tylenol). An antihistamine, such as diphenhydramine (Benadryl).

Aaron has been receiving antibiotic therapy for several days. He has a mild elevation in blood pressure and a 2 × 2 cm bruise in the antecubital space, where blood was obtained earlier that day, and has had 2 diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatoxicity related to antibiotic use. Which diagnostic test should the nurse request a prescription for to determine if Aaron is developing drug toxicity? Culture and sensitivity. Therapeutic index. Half life. Peak and trough.

Drug Intolerance

Half Life

Therapeutic Index

This test is performed to determine what microorganism is present and which antibiotic will be effective. This test should be performed prior to the initiation of antibiotic therapy.