Fundamentals of Nursing Chapter 19

The interference with circulation causes what to the skin?

• turgor

• eschar

• blanching

• pitting

Answer explanation

The interference with circulation causes the skin to blanch (turn white or, in darker skin, become pale). Page 303

Full thickness skin loss that looks like a deep crater is indicative of what?

• Stage 3 Pressure Injury

• Stage 1 Pressure Injury

• Stage 4 Pressure Injury

• Unstageable Pressure Injury

Answer explanation

Full-thickness skin loss that looks like a deep crater and may extend to the fascia is categorized as a stage 3 pressure injury. Subcutaneous tissue is damaged or necrotic. Fat is also visible. Page 305

How often should you provide mouth care to an unconscious patient?

• Every 3 hours.

• Every 2 hours.

• Once a shift.

• Every 4 hours.

Answer explanation

Provide full mouth care to an unconscious patient at least once every 4 hours, especially if the patient is mouth breathing. Mouth breathing causes the tongue to become dry and crusty. Remove any dry secretions because they may obstruct airflow or cause halitosis. Page 316

How are toenails to be cut?

• As the patient prefers.

• At an angle.

• Only by a podiatrist.

• Straight across.

Answer explanation

Use nail clippers to cut the toenails straight across to prevent them from growing into the skin along the sides. This can cause pain or infection and leads to ingrown toenails. Page 322

How are you to care for an artificial eye after removal?

• Cleanse it with normal saline.

• Sterilize it.

• Wash gently with warm tap water and hand soap.

• Rinse with cold tap water.

Answer explanation

Cleanse the artificial eye with normal saline. The edges of the eye socket may be cleansed with warm tap water or saline. Page 324