Which of the following assessments should be performed to monitor for impaired tissue integrity?
Pupil size and reaction
Heart rate and blood pressure
Respiratory rate and oxygen saturation
Skin turgor and moisture
The Correct Answer is D
A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Endogenous Infection: Endogenous infections originate from the client's own microbiota and typically do not involve medical interventions such as urinary catheterization.
B. Systemic Infection: Systemic infections affect the entire body and may not necessarily be related to the urinary tract.
C. Exogenous Infection: Exogenous infections originate from sources outside the client's body.
While the urinary tract infection could be caused by bacteria from the environment, it is more specifically categorized as a healthcare-associated infection (HAI) due to the indwelling urinary catheter being a risk factor.
D. Health Care-Associated Infection: A healthcare-associated infection (HAI) occurs as a result of healthcare interventions and can include infections related to urinary catheterization, surgery, or other medical procedures.
Correct Answer is ["B","D"]
Explanation
A. A phlebotomist is a technician specialized in drawing blood and does not play a role in identifying community health issues.
B. The Centers for Disease Control and Prevention (CDC) is a national public health agency that provides crucial data, research, and resources to address community health concerns and prevent pandemics.
C. The local fire and ambulance department primarily provides emergency services and is not focused on broader community health issues.
D. The World Health Organization (WHO) is an international public health agency that works to coordinate responses to health crises and identify global health trends, making it vital in addressing community health issues.
E. The American Nurses Association (ANA) supports nurses but does not primarily focus on identifying community health issues at the population level like the CDC or WHO.
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