The nurse is completing an assessment of the skin's integrity, ...

[lb_gilbert]

The nurse is completing an assessment of the skin's integrity, which includes
 
  a. Pressure points.
  b. All pulses.
  c. Breath sounds.
  d. Bowel sounds.

Question 2

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step?
 
  a. Remove the drain; a drain is no longer needed.
  b. Call the physician; a blockage is present in the tubing.
  c. Call the charge nurse to look at the drain.
  d. As long as the evacuator is compressed, do nothing.

[cascooper22]

Answer to Question 1

ANS: A
The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.

Answer to Question 2

ANS: B
Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.

[lb_gilbert]

TYSM

[frankwu0507]

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