Tissue Integrity
A patient has a pressure injury with intact skin but a localized area of non-blanchable redness over the sacrum.
What is a Stage 1 pressure injury?
This is a normal capillary refill time indicating adequate perfusion.
What is less than 3 seconds?
This is the priority intervention to prevent pressure injuries in immobile patients.
What is repositioning every 2 hours?
A patient suddenly becomes restless, has an O₂ sat of 88%, and is using accessory muscles to breathe. This is the FIRST nursing action.
What is apply oxygen?
This is the normal minimum urine output per hour for an adult.
What is 30 mL per hour?
This is the MOST important nursing action when a patient has redness over a bony prominence that does NOT blanch.
What is relieving pressure (offloading the area immediately)?
This skin finding indicates poor arterial blood flow and impaired perfusion.
What is cool, pale skin?
This exercise helps prevent deep vein thrombosis by promoting circulation in the legs.
What are ankle pumps (or leg exercises)?
A patient receiving Morphine has a respiratory rate of 8/min. This is the priority nursing action.
What is hold the medication and administer naloxone?
This urinary symptom includes burning or pain with urination.
What is dysuria?
A stoma that appears pale, dusky, or blue indicates this serious complication.
What is ischemia or necrosis?
A patient with confusion, low urine output, and hypotension is experiencing this type of perfusion problem.
What is systemic impaired perfusion?
This condition occurs when a patient’s blood pressure drops upon standing after immobility.
What is orthostatic hypotension?
A patient shows sudden confusion, unequal pupils, and slurred speech after a fall. This is the priority action.
What is activate a rapid response / notify the provider immediately?
This condition involves involuntary urine leakage when coughing or laughing.
What is stress incontinence?
A patient with impaired perfusion develops a worsening wound with black eschar and no pain. This underlying process is occurring.
What is tissue necrosis due to ischemia?
This condition is indicated by ST-segment elevation on an ECG.
What is a myocardial infarction (heart attack)?
This complication of immobility results in decreased muscle size and strength.
What is disuse atrophy?
A patient with suspected Clostridioides difficile infection is admitted. This precaution is required to prevent transmission.
What are contact precautions (gown and gloves)?
This finding (cloudy, foul-smelling urine) most commonly indicates this condition.
What is a urinary tract infection (UTI)?
A patient with incontinence develops skin breakdown from prolonged moisture exposure. This type of injury is classified as:
What is moisture-associated skin damage (MASD)?
This lab value increases when tissues are not getting enough oxygen and switch to anaerobic metabolism.
What is lactate?
This intervention is MOST effective in preventing venous thromboembolism in a patient on strict bed rest.
What are sequential compression devices (SCDs)?
A post-op patient has decreased urine output, hypotension, tachycardia, and cool clammy skin. This condition is MOST likely occurring and requires immediate intervention.
What is hypovolemic shock?
A patient has abdominal distention, absent bowel sounds, and suspected obstruction. This is the priority nursing action.
What is notify the provider and hold oral intake?