A patient is incontinent the first day after his surgery.
This is a risk factor for the development of skin breakdown and infection because of the added moisture and because:
The patient has to be repositioned for the bed to be changed.
Shearing is more likely from wet sheets.
The moisture creates an environment suitable for the growth of microorganisms in a wound.
Greater pressure is exerted by a wet bed.
The Correct Answer is C
Choice A rationale:
Repositioning the patient for bed changing does not directly contribute to skin breakdown or infection.
Choice B rationale:
While shearing can cause skin breakdown, it is not directly related to incontinence or wet sheets.
Choice C rationale:
Moisture from incontinence can create an environment suitable for the growth of microorganisms in a wound, leading to infection and skin breakdown.
Choice D rationale:
A wet bed does not exert greater pressure on the patient’s skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
E.
Choice A rationale:
Increased immunity is not a characteristic of aging. In fact, immunity decreases with age, which can slow healing.
Choice B rationale:
Atherosclerosis, or hardening of the arteries, can reduce blood flow to tissues and slow healing.
Choice C rationale:
Metabolism slows with age, which can delay the body’s ability to repair and regenerate tissues.
Choice D rationale:
Excessive production of blood factors is not a characteristic of aging. Blood factors are typically produced in response to injury or illness.
Choice E rationale:
Diminished lung function can reduce oxygen supply to tissues, slowing healing.
Correct Answer is C
Explanation
Choice A rationale:
A pressure injury is a general term for localized damage to the skin and underlying soft tissue, but it doesn’t specify the stage.
Choice B rationale:
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.
Choice C rationale:
Stage 1 pressure injuries are characterized by a reddened area on the skin that does not blanch with pressure.
Choice D rationale:
Stage 3 pressure injuries involve full-thickness skin loss.
Choice E rationale:
Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.
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