HESI Skin Integrity

Question 1

Scenario

Answer 1

A client with paraplegia as result of a spinal cord injury, received in a motorcycle accident, lives at home with their parents who assist with care. The client is attending college and has a strong social support system. The client visits the health clinic on campus for regularly scheduled skin assessment where the nurse observes a reddish area on their sacrum.

Question 2

The nurse observes that the reddish area is round and is directly over the client sacrum the skin is intact

In addition, to measuring the length of time, the redness lasts, which assessment measures should the nurse perform

Answer 2

1. Apply light pressure to the area with the fingertips.
   Rationale: the nurse applies light pressure with the fingertips to assess for blanching. Blanching is a normal response that indicates that there is no tissue perfusion impairment.
2. Measure the diameter of the redness.
   Rationale: the area of redness should be measured to evaluate progression or healing.

Question 3

The sacral area has remained red for two hours, and does not blanch when tested. Which is the best description for the nurse to document?

Answer 3

Reactive hyperemia.
Rationale: reactive, hyperemia occurs when tissue was relieved of pressure. It’s considered abnormal when the redness last longer than one hour, and the surrounding tissue does not blanch.

Question 4

The nurse identifies that the client has developed a stage one pressure ulcer and is concerned that the client may have other pressure ulcers

Which areas are most important for the nurse to observe for additional pressure ulcers?

Answer 4

Ischial Tuberosities.
 rationale: pressure ulcers typically occur over bone prominences, such as the heels, ankles, ischial tuberosities, and sacral area. The client is in a wheelchair, which makes the ischial tuberosities at greater risk for breakdown. Boney promises are the most common sites for pressure ulcer development. The nurse should perform a complete skin assessment.

Question 5

During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy

What action should the nurse implement?

Answer 5

Identify these areas as sites where pressure damage has occurred.
Rationale: palpable changes in the consistency of the tissue, underlying a bony prominence often described as spongy is an indication that pressure damage has occurred. Additional manifestations may include a change in skin, temperature and induration.

Question 6

The nurse identifies a priority problem for the clients plan of care as impaired skin integrity

Which etiology identified by the nurses accurate ?

Answer 6

Impaired physical mobility
Rationale since the client is paraplegic, they have impaired physical mobility, a major factor that contributes to pressure also development

Question 7

After establishing the priority diagnosis, the nurse identifies goals and expected outcomes
Which goal should the nurse include in the clients plan of care?

Answer 7

The client skin will remain intact without deterioration
Rationale: a goal should be a broad statement that includes, and positive terminology, the intended effect of the planning interventions

Question 8

At the end of the appointment, the nurse provides client teaching about measures to promote healing, and to prevent further tissue destruction
To provide pressure relief at night the nurse teaches a client to sleep in which position?

Answer 8

30° lateral inclined position
Rationale: this position reduces pressure on bony prominences, were pressure, ulcers frequently developed. Pillows and foam wedges may be used for support and protection in this position.

Question 9

Upon learning that the client has a pressure reducing gel chair cushion for their wheel wheelchair. Which action should the nurse take?

Answer 9

Encourage them to continue to use this device in their wheelchair at all times.
Rationale: these cushions help to redistribute weight, so that it is not all on the ischium. The client should also be instructed to shift weight frequently.

Question 10

A nurse teaches a client to apply dressing over the sacral area. Which type of dressing is most likely to be used over the stage one presser ulcer?

Answer 10

Transparent, film dressing.
Rationale: this type of dressing allows for visualization of the area and protect it from sheer

Question 11

A month later, the client arrives in the emergency department at the local hospital and reports having had the flu and had spent most of the time in bed for the last several days. The client has been experiencing vomiting and diarrhea. The nurse observes that the sacral ulcer is open, as a crater like appearance, and is draining a large amount of thick yellow tan fluid with an unpleasant odor. A small amount of eschar is present. The client is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis.

How should the nurse describe the drainage and documenting the wound?

Answer 11

Purulent.
Rationale: purulent refers to something that contains or produces pus. Pus is an indication that infection is likely.

Question 12

To reduce the effects of moisture on the client skin, which intervention should be implemented?

Answer 12

Apply a moisture repellent ointment to intact skin areas.
Rationale: after the skin is clean and dried moisture repellent ointment should be applied to protect and moisturize the skin. Fecal toxins are damaging to tissue and excessive moisture causes skin maceration and damage.

Question 13

The nurse prepares a written, positioning schedule and places it in the clients room as a reminder for the UAP assigned to help with the clients care. The charge nurse removes the schedule and states that it violates the clients privacy.

What action should the nurse take?

Answer 13

Assure the charge nurse that written instructions in the clients room, are effective and do not violate any clients rights.
Rationale: a written, individualized schedule is the most effective method to ensure consistent positioning, and may be placed in the client room without compromising client confidentiality

Question 14

A wound culture indicates that the clients wound is infected with methicillin resistant staphylococcus aureus (MRSA).

After reviewing the results of the wound culture, which type of precaution, should the nurse and staff use when caring for this client?

Answer 14

Contact precautions.
Rationale: the client should be cared for using contact precautions when there is a potential for wound drainage and debris to splatter during care of transmission of MRSA includes direct contact, as well as contact with infected surfaces

Question 15

The nurse suspects that the clients wound has developed a sinus tract or tunneling

Which equipment should a nurse utilize to assess the length of the tract ?

Answer 15

Sterile, cotton tipped applicator.

Rationale: a sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton tipped to determine the location and length of the tunneling. Once length is noted with applicator, then use tape measure to document exact length .

Question 16

The nurse notifies the healthcare provider of sinus tracks, discovered during the assessment and receives a prescription to irrigate the wound with sodium chloride 0.9%

Which irrigation technique is best?

Answer 16

Apply steady pressure using a 35 ML syringe and 19 gauge needle
Rationale: using a 35 ML syringe and 19 gauge needle provides 8 pounds per square inch (Psi) which applies Adequate pressure to ensure effective irrigation. Safe, effective pressure is between four and 15 psi. More than 15 Psi Will drive bacteria into the wound and destroy healthy tissue.

Question 17

Following wound irrigation, the nurse plans to apply a wet to dry dressing.

What is the purpose of this type of dressing?

Answer 17

Mechanically debride the tissue.
Rationale: moist gauze is placed on the wound and allowed to dry. It is then adherence to the wound, tissue and debris, necrotic or infected tissue as it is removed.

Question 18

The nurse plans to administer a prescribed dose of linezolid, an antibiotic, which interferes with the production of proteins that bacteria Need to multiply and divide. The prescription states, “linezolid suspension 400 mg PO every 12 hours for 4 days.” the medication is labeled “ 100 mg per 5 mL”.
What is the total daily dosage (in milligrams) that the client will be receiving?

Answer 18

800 mg

Rationale 400 mg times two daily doses (every 12 hours) equals 800 mg/24 hours

Question 19

Before pouring the suspension, the nurse determines that the medication and dose on the bottles label are correct as prescribed but the client name listed on the bottle is incorrect.
Who is the best member of the interdisciplinary team for the nurse to collaborate with to restore this discrepancy?

Answer 19

Pharmacist.
Rationale: incorrectly labeled medication’s are the responsibility of the pharmacist

Question 20

When the medication bottle is properly labeled, a nurse mixes the suspension prior to pouring it

Which technique should the nurse use to mix the linezolid?

Answer 20

According to directions

Rationale: ruction should be to 2 to 3 times, avoiding shaking, according to manufacturer specifications. Linezolid should never be shaken.

Question 21

The nurse correctly uses which technique when pouring the suspension?

Answer 21

Place some medication cup on a flat surface at eye level

Rationale: to safely measure the prescribed dose, the medication cup must be on a flat surface at eye level

Question 22

Ongoing monitoring: the nurse monitors lab values and assesses for adverse effects during the course of the clients treatment with linezolid.

During the course of the antibiotic treatment with linezolid which of the client serum laboratory values require intervention by the nurse?

Answer 22

Platelet count
Rationale: this medication has been shown to decrease platelet count. Normal platelet count is 132, 400×103/MCL.

Question 23

Prior to administering the first dose of the antibiotics, the nurse asks the client about any drug allergies.
The nurse explains to the client that this precaution reduces the risk for what potential problem?

Answer 23

Anaphylactic reaction.
Rationale: an anaphylactic reaction is a severe allergic reaction that can be life-threatening.

Question 24

After the client receives the first dose of linezolid the nurse reports to the healthcare provider that a rash and itching develop on his thorax, but he has no respiratory symptoms

Which class of medication should the nurse expect to administer?

Answer 24

And antihistamines, such as diphenhydramine.
Rationale: an antihistamine should control the itching and rash of the reaction. Rash and itching are identified side effects of linezolid. The nurse, however, continue to monitor for more severe allergic response.

Question 25

The client has been receiving antibiotic therapy for several days. The client has a mild elevation and blood pressure and a two ×2 cm bruise in the ankle space where blood was obtained earlier that day and has had two diarrhea stools and four hours. The nurse is concerned that he is exhibiting science of hepatotoxicity related to antibiotic use

Which diagnostic test should the nurse request in order to determine if the client is developing drug toxicity?

Answer 25

Peak and trough

Rationale: serum drug levels are obtained at the highest and lowest levels, which provide useful information regarding the amount of drug the individual client has in the bloodstream. If the troph is greater than the acceptable limit for the drug, the next deal should be withheld in the blood level rechecked six hours later .

Question 26

No evidence of drug toxicity is found. The clients next BP is within normal limits, and experiences no further episodes of diarrhea. The wound Esker has been removed, and there is no further drainage. Hydrocolloid dressing is placed over the wound, and the client is discharged. The client will complete the two week antibiotic treatment at home. The homecare nurse visits the client a week after discharge to assess the wound. The nurse reviews symptoms of pressure ulcers with the client, as well as when to call the HCP. The client yells at the nurse and says that they do not need a nurse to tell them that they will spend the rest of their life in and out of hospitals.

Which initial action should the nurse take?

Answer 26

Offer the client, the opportunity to discuss their feelings of anger.
Rationale: use therapeutic communication techniques, the nurse can provide the opportunity for the client to deal with his concerns

Question 27

The client apologizes to the nurse and expresses how discouraged they are about the bed sore and the infection.

Which nurse being response Best promotes effective communication?

Answer 27

Hope the client identify the concerns he is trying to cope with at this time.
Rationale: this response acknowledges the clients experience, and encourages further insight and verbalization by the client

Question 28

Considering the clients developmental stage at the edge of 20, the nurse plans of care emphasizes interaction with which group?

Answer 28

The client’s girlfriend, and his two best male friends from college.
Rationale: as a young adult, the clients primary developmental task, according to the theorist, Erikson, is to develop intimacy. The nurse should emphasize interaction with a small group of intimate friends to support the developmental task.

Question 29

It is most important to include this group and watch aspect of the clients overall care?

Answer 29

Reviewing class notes and studying for exams.
Rationale: the young adult is a developmentally involved in establishing intimacy and working toward future goals. And addition, studying with his peers will help maintain a sense of normalcy for the client. Other tasks can easily be performed by other groups, such as family members. This task can be best performed by his peers.

Question 30

The home care nurse teaches a client about dietary measures to promote wound, healing and emphasizes the need for extra protein.

The nurse encourages the client to select which breakfast items to provide a good source of protein?

Answer 30

Eggs and orange juice
Rationale: eggs are a good source of protein, iron, and zinc, which are all important for wound healing. Citrus juices, such as orange juice are a good source of vitamin C, which is also important for wound healing.

Question 31

The home care, nurse, observes that the clients ulcer is red, with obvious granulation tissue filling in the ulcer crater

What teaching should the nurse provide?

Answer 31

Hydrocolloid dressing should be continued over the ulcer.
Rationale: the healing ulcer continues to need for the protection and moist environment provided by hydrochloride dressings