Tissue Integrity

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Sample questions from Tissue Integrity

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At 0800 on a medical-surgical unit, a 74-year-old client with diabetes has a sacral pressure injury and a temperature of 38.4 C. The wound-care nurse reports increased drainage, and the client is newly confused. Which action should the nurse take first?

   • A.Request a dietary consult for increased protein intake
   • B.Document the findings and reassess in 4 hours
   • C.Assess the client and notify the provider of possible systemic infection
   • D.Apply a hydrocolloid dressing to the wound

   Rationale: New confusion, fever, and increased wound drainage suggest infection with possible systemic involvement, so prompt assessment and provider notification are needed. A dressing change and nutrition consult may be appropriate later but do not address possible acute deterioration. Waiting 4 hours risks delaying treatment. The exam takeaway is to prioritize acute systemic changes over routine wound care.

2. 2.During a home visit, a 79-year-old client with limited mobility has a nonblanchable red area over the heel. The client is afebrile, and the skin is intact. Which interventions should the nurse include in the plan of care? Select all that apply.

   • A.Float the heel so it does not rest on the mattress
   • B.Reposition the client on an individualized schedule
   • C.Use a donut-shaped device beneath the heel
   • D.Massage the reddened area every shift
   • E.Assess nutrition and hydration
   • F.Keep the skin clean and manage moisture

   Rationale: Floating the heel, individualized repositioning, attention to nutrition and hydration, and moisture management reduce pressure and skin injury risk. Massaging nonblanchable erythema can damage tissue further. Donut-shaped devices concentrate pressure around their edges and should be avoided. The findings suggest an early pressure injury, so relieving pressure is a priority.

3. 3.At change of shift on a surgical unit, a 62-year-old client with a dehisced abdominal incision is alert and has stable vital signs. The wound is covered with a sterile saline-moistened dressing. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Measure and report the client's temperature
   • B.Teach the client how to splint the incision
   • C.Assess the wound for increasing separation
   • D.Change the sterile dressing

   Rationale: Measuring and reporting temperature is a routine task that can be delegated to a trained UAP. Wound assessment, sterile dressing changes, and teaching require nursing judgment or skill and remain the nurse's responsibility. The nurse should give clear parameters for promptly reporting an elevated temperature. Delegation does not transfer accountability for follow-up.

4. 4.In an outpatient clinic, a 56-year-old client taking warfarin reports a new bruise and bleeding from a small skin tear. The INR is 5.2 (usual goal 2.0-3.0), and vital signs are stable. Which action is the priority?

   • A.Arrange routine follow-up in 1 month
   • B.Apply firm pressure to the skin tear and notify the provider about the INR
   • C.Clean the tear with hydrogen peroxide
   • D.Instruct the client to take the next warfarin dose with food

   Answer and rationale are in the full material.

5. 5.On a rehabilitation unit, a 68-year-old client with a stage 3 pressure injury has a wound bed with granulation tissue and moderate exudate. Which team member should the nurse consult to address a key factor in wound healing?

   • A.Speech-language pathologist to assess swallowing
   • B.Pharmacist to review the client's vision medications
   • C.Respiratory therapist to assess cough strength
   • D.Dietitian to assess protein and calorie intake

   Answer and rationale are in the full material.