Author Question: The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids. The ... (Read 54 times)

cmoore54 · **on:** Jul 22, 2018

The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids. The greatest risk exists for the client who has exposure to which one of the following fluids?

a. Urine
b. Purulent exudates
c. Pancreatic fluids
d. Serosanguineous drainage

Question 2

On admission to the hospital, a client with terminal cancer says that he has a living will. Which of the following does this document state as the client's desire?

a. Receive all means of mechanical assistance to prolong life
b. Have his wife make decisions regarding his care
c. Be allowed to die and not be subject to life-prolonging measures
d. Have a lethal injection administered to free him from his suffering

Jane · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. A client whose skin is exposed to excessive moisture has an increased risk of skin breakdown due to changes in skin pH and maceration of skin.
Exposure to urine, bile, stool, acidic fluid, and purulent wound exudates carries a moderate risk for skin breakdown.
Exposure to urine, bile, stool, acidic fluid, and purulent wound exudates carries a moderate risk for skin breakdown.
Serosanguineous drainage is not caustic to the skin, and the risk of skin breakdown from expo-sure to this fluid is low.

Answer to Question 2

C
A living will is a document in which a person records refusal of life-prolonging measures that may be administered during his or her probable state of mental incompetence in the future.
A living will specifies what life-prolonging interventions the client does not want for himself or herself.
If the client's wife had been appointed by him as his health care agent, then she could make treatment decisions on his behalf.
Assisted suicide, such as a lethal injection, is not a function of a living will. A living will defines a client's wishes for withholding life-prolonging treatments.