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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Place the client in a private room.
- Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
Administer intravenous vancomycin.
- Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
Wear a cover gown when caring for the client.
- Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
Restrict fluid intake.
- Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
Initiate supplemental oxygen.
- Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.

A. Avoiding use of a urinary catheter B. Applying absorbent briefs C. Restricting Fluids D. Toileting patient every 4 hours

Correct Answer is B

Explanation

A. Avoiding use of a urinary catheter: While avoiding unnecessary urinary catheterization is important to prevent healthcare-associated urinary tract infections, this action may not be directly applicable to an incontinent patient who requires interventions to manage incontinence.
B. Applying absorbent briefs: Using absorbent briefs helps contain urine and feces, reducing the risk of skin breakdown and contamination of the environment.
C. Restricting Fluids: Restricting fluids may lead to dehydration and is not a recommended approach for preventing healthcare-associated infections in incontinent patients.
D. Toileting patient every 4 hours: Toileting frequency should be individualized based on the patient's needs and not restricted to a specific time interval. Additionally, simply toileting the patient may not be sufficient to prevent healthcare-associated infections if proper hygiene practices are not followed.

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Which of the following assessments should be performed to monitor for impaired tissue integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

Correct Answer is B

Explanation

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