Which of the following signs is most indicative of impaired skin integrity?

Skin feeling warm to the touch

Presence of a wound with partial thickness skin loss

Dry skin with no visible lesions

Slight redness of the skin after applying pressure

Answer and Explanation

The Correct Answer is B

A. Skin feeling warm to the touch. This is incorrect because warmth may indicate inflammation, infection, or increased blood flow, but it does not necessarily mean the skin’s integrity is impaired. Skin integrity refers to the structural intactness of the skin.

B. Presence of a wound with partial-thickness skin loss. This is correct because partial-thickness skin loss indicates that the protective barrier of the skin has been compromised. This is a clear sign of impaired skin integrity, which requires appropriate assessment and intervention to promote healing and prevent infection.

C. Dry skin with no visible lesions. This is incorrect because while dry skin may be at risk for breakdown, it does not indicate that the skin is currently impaired. Intact dry skin still maintains its structural integrity.

D. Slight redness of the skin after applying pressure. This is incorrect because transient redness that disappears after pressure relief is not necessarily a sign of skin breakdown. However, if redness persists (non-blanchable erythema), it may indicate a stage 1 pressure injury, which would then suggest potential skin integrity impairment.

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Correct Answer is D

Explanation

A. Direct the nursing assistive personnel to give the acetaminophen. This is incorrect because administering medication is outside the scope of practice for nursing assistive personnel. Only licensed nurses are authorized to administer medications.

B. Perform a pain assessment only after administering the acetaminophen. This is incorrect because a pain assessment should be conducted before administering a PRN medication to determine the severity and characteristics of the pain.

C. Notify the health care provider to obtain a verbal order. This is incorrect because the medication is already included in the standing orders. There is no need to obtain a verbal order when the medication has already been prescribed with specific administration parameters.

D. Administer the acetaminophen. This is correct because the nurse has assessed the patient’s need for pain relief, confirmed that the patient has not received the medication in the past four hours, and verified that it falls within the provider’s orders. Since all criteria are met, the nurse should proceed with administering the medication as prescribed.

A. The patient reports increased pain and limited range of motion B. The patient experiences frequent falls and difficulty maintaining balance C. The patient is able to independently walk with a walker D. The patient has difficulty ambulating without assistance

Correct Answer is C

Explanation

A. Increased pain and frequent falls indicate unmet outcomes.
B. Frequent falls indicate unmet outcomes.
C. This demonstrates progress toward independence in mobility.
D. Difficulty ambulating shows ongoing impairment.

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Which of the following signs is most indicative of impaired skin integrity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Correct Answer is D

Explanation

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

Correct Answer is C

Explanation

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

Which of the following signs is most indicative of impaired skin integrity?

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Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?