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 B
Explanation
A. A person with diabetes who requires hospitalization for cellulitis: Cellulitis may not necessarily be a healthcare-associated infection unless it developed as a complication during the hospitalization.
B. Pneumonia in a hospitalized patient: Pneumonia acquired during a hospital stay is considered a healthcare-associated infection (HAI) because it develops after 48 hours of hospital admission.
C. Chronic urinary tract infection for a homebound patient: A chronic urinary tract infection in a homebound patient is not automatically considered a healthcare-associated infection unless it can be directly linked to healthcare interventions or devices.
D. A sexually transmitted infection in a healthy young adult: Sexually transmitted infections are not healthcare-associated infections as they are typically acquired through sexual contact rather than healthcare settings.
Correct Answer is A
Explanation
A. Perform hand hygiene before, during, and after direct contact with the client: Hand hygiene is one of the most effective strategies to interrupt the transmission of infections. It helps prevent the spread of pathogens from one person to another, reducing the risk of healthcare-associated infections.
B. Encourage the client to consume a diet high in protein: While proper nutrition is important for overall health and immune function, it does not directly address the transmission of the client's infection.
C. Change the client's bed linens each day: Changing bed linens regularly is important for maintaining cleanliness and comfort but is not sufficient to interrupt the transmission of infection.
D. Place the client in a room with positive pressure airflow: Positive pressure airflow rooms are typically used for patients with compromised immune systems to protect them from airborne pathogens. This strategy is not applicable for all types of infections and may not be necessary for every client with an infection.
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