ATI fundamentals proctored exam
- The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.)
- Administer ordered analgesic 1 hour before bath time.
- Increase the frequency of skin assessment.
- Reduce triggers in the environment.
- Keep the room temperature cool.
- Be as quick as possible.
ANS: B, C
If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment. Adapt your bathing procedures and the environment to reduce the triggers. For example, administer any ordered analgesic 30 minutes before a bath and be gentle in your approach. Keep the patient’s body as warm as possible with warm towels and be sure the room temperature is comfortable.
- The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.)
- Abnormal gait
- Foot deformities
- Absent or decreased pedal pulses
- Muscle wasting of lower extremities
- Decreased hair growth on legs and feet
ANS: A, B, D
A patient with peripheral neuropathy has muscle wasting of lower extremities, foot deformities, and abnormal gait. A patient with vascular insufficiency will have decreased hair growth on legs and feet, absent or decreased pulses, and thickened nails.
- A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.)
- Do not rinse.
- Clean under breasts.
- Inform that the skin will feel sticky.
- Dry thoroughly between skin folds.
- Use two wipes for each area of the body.
ANS: A, B, C
CHG wipes are easy to use and accessible for older patients and bariatric patients, offering a no-rinse or -drying procedure. For a bariatric patient or a patient who is diaphoretic, provide special attention to body areas such as beneath the woman’s breasts, in the groin, skin folds, and perineal area, where moisture collects and irritates skin surfaces. Use wipes as directed on package—one wipe per each area of the body. CHG can leave the skin feeling sticky. If patients complain about its use, you need to explain their vulnerability to infection and how CHG helps reduce occurrence of health care–associated infection.
- Which patients will the nurse determine are in need of perineal care? (Select all that apply.)
- A patient with rectal and genital surgical dressings
- A patient with urinary and fecal incontinence
- A circumcised male who is ambulatory
- A patient who has an indwelling catheter
- A bariatric patient
ANS: A, B, D, E
Patients most in need of perineal care include those at greatest risk for acquiring an infection (e.g., uncircumcised males, patients who have indwelling urinary catheters, or those who are recovering from rectal or genital surgery or childbirth). A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling. Bariatric patients need special attention to body areas such as skin folds and the perineal area. In addition, women who are having a menstrual period require perineal care. Circumcised males are not at high risk for acquiring infection, and ambulatory patients can usually provide perineal self-care.
- The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)
- Apply sterile gloves.
- Keep soiled linen close to uniform.
- Advise patient will feel a lump when rolling over.
- Turn clean pillowcase inside out over the hand holding it.
- Make a modified mitered corner with sheet, blanket, and spread.
ANS: C, D, E
When making an occupied bed, advise patients they will feel a lump when turning, turn clean pillowcase inside out, and make a modified mitered corner. Clean gloves are used. Keep soiled linen away from uniform.
Chapter 48: Skin Integrity and Wound Care
Potter et al.: Fundamentals of
Nursing, 9th Edition MULTIPLE CHOICE
- The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?
- Decreased level of consciousness
- Adequate dietary intake
- Shortness of breath
- Muscular pain
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are not included among the predisposing factors.
- The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which
priorityelement will the nurse consider when planning care to decrease the development of a decubitus ulcer?
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.
- Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
- The patient has fecal incontinence.
- The patient ate two thirds of breakfast.
- The patient has a raised red rash on the right shin.
- The patient’s capillary refill is less than 2 seconds.
The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.
- The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient’s medical record?
- Stage I pressure ulcer
- Healing Stage II pressure ulcer
- Healing Stage III pressure ulcer
- Stage III pressure ulcer
When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words “healing stage” or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage III.
- The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without
slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
- Stage I
- Stage II
- Stage III
- Stage IV
This would be a Stage II pressure ulcer because it presents as partialthickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.