Author Question: The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The ... (Read 118 times)

@Brianna17 · **on:** Jul 23, 2018

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 · **Reply #1 on:** Jul 23, 2018

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.