The nurse recognizes that skin integrity can be compromised by ...

[@Brianna17]

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to:
 
  1. Urine
  2. Purulent exudates
  3. Pancreatic fluids
  4. Serosanguineous drainage

Question 2

The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape:
 
  1. At a 45-degree angle to the skin surface while pulling away from the wound
  2. At a right angle to the skin surface while pulling toward the wound
  3. At a right angle to the skin surface while pulling away from the wound
  4. Parallel to the skin surface while pulling toward the wound

[tofugiraffe]

Answer to Question 1

ANS: 3
Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low.

Answer to Question 2

ANS: 4
To remove tape safely, the nurse loosens the tape ends and gently pulls the outer end parallel with the skin surface toward the wound. Tape should not be pulled in a direction away from the wound because this may cause the wound edges to separate. Holding the tape at a right angle to the skin surface may pull on the wound bed, causing separation of wound layers, or may damage the underlying skin.

[@Brianna17]

Thanks for the timely response, appreciate it

[rachel]

Gracias!