1. The nurse is updating the plan of care for a patient with impaired skin

integrity. Which findings indicate achievement of goals and outcomes? (Select

all that apply.)

a. The patient’s expectations are not being met.

b. Skin is intact with no redness or swelling.

c. Nonblanchable erythema is absent.

d. No injuries to the skin and tissues are evident.

e. Granulation tissue is present.

ANS: B, C, D, E

Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin,

reduce injury to underlying tissues, and restore skin integrity. Skin intact,

nonblanchable erythema absent, no injuries, and presence of

granulation tissue are all findings indicating achievement of goals and outcomes.

The patient’s expectations not being met indicates no progression toward

goals/outcomes.

MATCHING

The nurse is caring for patients who need wound dressings. Match the type of

dressing the nurse applies to its description.

a. Absorbs drainage through the use of exudate absorbers in the dressing

b. Very soothing to the patient and do not adhere to the wound bed

c. Barrier to external fluids/bacteria but allows wound to “breathe”

d. Manufactured from seaweed and comes in sheet and rope form

e. Oldest and most common absorbent dressing

1. Gauze