TISSUE INTEGRITY ATI|UPDATED&VERIFIED|100% SOLVED|GUARANTEED SUCCESS

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? You should shift your weight off your buttocks at intervals throughout the day *The nurse should instruct the client to shift their weight to relieve pressure on the sacral area at regular intervals throughout the day. This action will increase circulation to the tissues and prevent skin breakdown. A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? Pressure injury documentation includes location, stage, measurements and condition of the wound bed and any drainage present *When documenting pressure injuries, the nurse should include the location, stage, size, description of tissue, color of the wound bed, condition of surrounding tissue, appearance of wound edges, presence of undermining and tunneling, and any foul odor present. The nurse should also document the presence and characteristics of any wound drainage observed. Any reports of pain at the wound site should also be documented. A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and call for help. Which of the following actions should the nurse take? Cover the client's wound with a sterile saline dressing *The nurse should place a sterile, saline-soaked dressing over the client's wound to prevent the dressing from adhering to the tissue and protect the organs until the client is taken back to surgery. A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? The skin of older adults is thinner and has less subcutaneous padding over bony prominences *As an individual ages, expected changes occur in the skin, including a decrease in elasticity and subcutaneous tissue. This increases the risk of injury to the skin for older adults. A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take? Clean the wound with 0.9% sodium chloride *To collect a wound culture using a sterile cotton applicator, the nurse should first clean the wound with 0.9% sodium chloride to rinse away any resident bacteria that may be present. A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications? Dehiscence *Dehiscence is a separation of part or all of the wound edges. This is a common complication after abdominal surgery, where the client experiences a ripping sensation at the wound site. A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching? Your staples will be removed in about 2 weeks *In general, wounds that are closed with staples heal faster than wounds that are sutured. Staples can be removed within 7 to 14 days. A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? A client who is incontinent and taking a prescribed diuretic *Clients who are incontinent have an increased risk for developing alterations in tissue integrity, such as maceration, due to prolonged exposure to moisture. A nurse is caring for a client who has dime-sized stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use? A transparent film *Due to their reduced ability to absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate. A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching The skin assists in the regulation of body temperature *The main functions of the skin are to provide a barrier from injury, infection, and ultraviolent radiation, as well as control fluctuations in body temperature. A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury? Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue *A stage 3 pressure injury is characterized by full-thickness skin loss and visible adipose tissue. The fascia, muscles, tendons, bone, ligament, and cartilage are not visible in this stage. A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? A clients who has a Braden scale score of 9 *The lowest overall score a client can receive on the Braden Scale is a 6, with 23 being the maximum score. The lower the overall score the client receives, the greater the risk the client has for alterations in skin and tissue integrity. Therefore, this client has the greatest risk for alterations in skin integrity. A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching? "I should increase my protein intake." *Foods high in protein are essential for wound healing and tissue strengthening. Foods high in omega-3 and omega-6 fatty acids and foods with vitamins A and C also aid in wound healing. A nurse is planning care for an older adult clients who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown? Tilt the client on their side at 30 degrees *The nurse should include in the client's plan of care to tilt the client on their side at 20° to 30°. This prevents the client from sliding down in bed, which can cause shearing of the skin, while also relieving pressure to the client's hip.