HESI Case Study: Skin Integrity Written Exam Questions With Well Elaborated Answers.

the nurse observes that the reddish area is round and is directly over the client's sacrum. the skin in intact. 1. in addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - correct answer - apply light pressure to the area with the fingertips (the RN applies light pressure with the fingertips to assess for blanching. this is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairment) - measure the diameter of the redness (the area of redness should be measured to evaluate progression or healing) 2. the sacral area has remained red for 2 hours and does not blanch when tested. which is the best description for the nurse to document? - correct answer reactive hyperemia (reactive hyperemia occurs when tissue is relieved of pressure. it is considered abnormal when the redness lasts longer than 1 hour and the surrounds tissue does not blanch) the nurse identifies that Alexander has developed a stage 1 pressure ulcer and is concerned that Alexander may have other pressure ulcers. 3. which areas are most important for the nurse to observe for additional pressure ulcers? - correct answer heels and ankles (pressure ulcers typically occur over bony prominences. such as the heels, ankles, and sacral area. while bony prominences are the most common sites for pressure ulcer development, the RN should perform a complete skin assessment) during the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. 4. what action should the nurse implement? - correct answer identify these areas as sites where pressure damage has occurred (palpable changes in the consistency of the tissue underlying a bony prominence, often described as "spongy" an indication that pressure damage has occurred. additional manifestations may include a change in skin temperature and induration) the nurse identifies a priority problem for Alexander's plan of care as "impaired skin integrity." 5. which etiology identified by the nurse is accurate? - correct answer impaired physical mobility (since Alexander is paraplegic, he has impaired physical mobility, a major factor that contributes to pressure ulcer development) after establishing the priority diagnosis, the nurse identifies goals and expected outcomes 6. which goal will the nurse include in Alexander's plan of care? - correct answer client's skin will remain intact (a goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions) at the end of the appointment, the nurse provides client teaching about measures to promote healing and to prevent further tissue destruction 7. to provide pressure relief at night, the nurse teaches Alexander to sleep in which position? - correct answer thirty-degree lateral inclined position (this position best reduces pressure on bony prominences where pressure ulcer frequently develop. pillows and foam wedges may be used for support and protection in this position) 8. upon of learning that Alexander has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take? - correct answer encourage him to continue to use this device in his wheelchair at all times (these cushions help redistribute weight so that it is not all on the ischium. the client should also be instructed to shift weight frequently) 9. the nurse teaches Alexander to apply a dressing over the sacral area. which type of dressing is most likely to be used over the stage 1 pressure ulcer? - correct answer transparent film dressing (this type of dressing allows for visualization of the area and protects it from shear) a month later, Alexander arrives in the emergency department at the local hospital. he reports that 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. Alexander is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. 10. which documentation best describes the drainage from Alexander's wound? - correct answer purulent (purulent refers to something that contains or produces pus. pus is an indication that an infection is likely) 11. which intervention is important to reduce the effect of the diarrhea an Alexander's skin? - correct answer apply a moisture-repellent ointment to intact skin areas (after the skin is cleaned and dried, a moisture-repellent ointment should be applied to protect and moisturize the skin. fecal toxins are damaging to tissue, and excessive moisture causes skin maceration and damage) the nurse prepares a written positioning schedule and places it in Alexander's room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with Alexander's care. the charge nurse removed the schedule and states that it violates Alexander's privacy. 12. what action should the nurse take? - correct answer assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights (a written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client's room without compromising client confidentiality) a wound culture indicates that Alexander's wound in infected with methicillin-resistant Staphylococcus aureus (MRSA). 13. after reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client? - correct answer contact precautions (the client should be cared for using contact precautions when there is potential for wound drainage and debris to splatter during care. the mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces the nurse suspects that Alexander's wound has developed a sinus tract, or tunneling 14. what equipment will the nurse use to assess the length of the tract? - correct answer sterile cotton-tipped applicator (a sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the location and length of the tunneling) after assessing for sinus tracts, the nurse irrigates the wound as prescribed with normal saline 15. which irrigation technique is best? - correct answer apply steady pressure using a a 35mL syringe and 19 gauge needle (using a 35mL syringe and 10 gauge needle provides 8 pounds per square inch (PSI), which applies adequate pressure to ensure effective irrigation. safe, effective pressure between 4 and 15 PSI. more than 15 PSI will drive bacteria into the wound and destroy healthy tissue) following wound irrigation, the nurse plans to apply wet-to-dry dressing 16. what is the best purpose of this type of dressing? - correct answer mechanically debride the tissue (moistened gauze is places on the wound and allowed to dry. it then adheres to the wound tissue and debrides necrotic or infected tissue as it is removed) the nurse plans to administer a prescribed dose of linezolid (zyvox), an antibiotic, with interferes with the production of proteins that bacteria need to multiply and divid. the prescription states, "Linezolid suspension 400mg PO q 12 for 14 days." the medication is labeled, "100mg/5 mL) 17. how many mL of medication will the nurse administer? - correct answer 20 (400mg/100mg x 5mL = 20mL) the prescription states, "Linezolid suspension 400mg PO q12 for 14 days." the medication is labeled, "100mg/5mL." the nurse is scheduled to administer 20mL. The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 to 1200mg. 18. what is the total daily dosage (in mg) that Alexander will be receiving? - correct answer 800 (400mg x 2 daily doses (every 12 hours) = 800mg/24 hours) before pouring the suspension, the nurse determines that the medication and dose on the bottle's label are correct as prescribed, but the client name listed on the bottle is incorrect. 19. who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy? - correct answer pharmacist