Exam 21: Tissue Integrity

A client has a wound of the left lateral aspect of the thigh.Which action by the nurse promotes wound healing for this client?

A client has a pressure ulcer on the medial malleolus.The client's skin is intact with purple discoloration and a blood-filled blister.When documenting this finding,which terminology is appropriate for the nurse to use?

While assessing the feet and ankles of an older adult client,the nurse presses a finger into the client's skin in order to create an indentation.For what is the nurse assessing?

An older adult client with friable skin and poor skin turgor has slipped down in the bed.Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown?

A client is evaluated after suffering severe burns to the torso and upper extremities.The nurse notes edema at the burned areas.Which best describes the underlying cause for this manifestation?

An older adult client with severe burns over more than half of the body has an indwelling catheter.When evaluating the client's intake and output,which should be taken into consideration?

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake.Which laboratory value is the best indicator of nutritional status?

The nurse identifies a client at risk for contact dermatitis.Which assessment findings support the nurse's assumption? Select all that apply.

A nurse working in the intensive care unit (ICU)is caring for a client who is 10 days postoperative after open abdominal surgery.The client has a well-approximated midline surgical incision that has numerous staples and a "healing ridge" noted.Which healing phase best describes the incision?