Skin Integrity Risk Factors Worksheet

A nurse is caring for a client who is diaphoretic. The nurse should recognize that this client is at increased risk for which skin complication?

• Pressure ulcer due to reduced mobility

• Maceration and skin breakdown due to excessive moisture

• Fungal infection due to elevated body temperature

• Dehydration due to fluid loss

Which client is at the greatest risk for developing pressure ulcers?

• A. A client with an IV antibiotic for pneumonia

• B. A client who is immobilized and unable to reposition themselves

• C. A client who ambulates with a walker

• D. A client with controlled hypertension

A client with diabetes is at an increased risk for impaired skin integrity primarily because of:

• poor circulation

• excessive sweating

• increased mobility

• high protein intake

A nurse is assessing a client who was bitten by a cat on the hand three days ago. Which finding indicates the client is developing a systemic infection?

• Redness and swelling at the bite site

• Pus drainage from the wound

• Fever, chills, and positive blood cultures

• Tenderness at the bite site only

Which finding should the nurse expect in a client with a localized wound infection?

• Low-grade fever and generalized malaise

• Positive blood cultures

• Redness, warmth, and purulent drainage at the wound site

• Hypotension and tachycardia

What are the signs of infection at the wound site?

• C. Redness, warmth, and purulent drainage at the wound site

• A. Pale, cool, and dry skin at the wound site

• B. Decreased sensation and absence of swelling at the wound site

• D. Blue discoloration and absence of pain at the wound site

A nurse is reviewing laboratory results for a client suspected of having an infection. Which finding supports this diagnosis?

• Decreased red blood cell (RBC) count

• Increased platelet count

• Elevated white blood cell (WBC) count

• Decreased hemoglobin level

What is the most effective method for preventing the spread of infection in healthcare settings?

• Wearing sterile gloves during all client care

• Using alcohol-based hand sanitizer only after contact with body fluids

• Performing thorough hand hygiene before and after client contact

• Wearing a mask when entering a client’s room

The nurse is educating staff about infection prevention. Which statement indicates correct understanding about nail care?

• Artificial nails are acceptable if kept clean

• Long natural nails are safe if polished regularly

• Nails should be kept short and clean to prevent bacterial buildup

• It is not necessary to clean under the nails if gloves are worn

A client is diagnosed with pertussis. Which transmission-based precaution should the nurse implement?

• Contact precautions with gown and gloves

• Droplet precautions with a surgical mask

• Airborne precautions with an N95 respirator

• Protective environment precautions