The nurse recognizes that skin integrity can be compromised when skin is exposed to body fluids. The greatest risk exists for the patient who has exposure to which one of the following fluids?
a. Urine
b. Purulent exudates
c. Pancreatic fluids
d. Serosanguineous drainage
C
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A Exposure to urine, bile, stool, acidic fluid, and purulent wound exudates carries a moderate risk for skin breakdown.
B Exposure to urine, bile, stool, acidic fluid, and purulent wound exudates carries a moderate risk for skin breakdown.
C Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. A patient whose skin is exposed to excessive moisture has an increased risk of skin breakdown due to changes in skin pH and maceration of skin.
D Serosanguineous drainage is not caustic to the skin, and the risk of skin breakdown from exposure to this fluid is low.
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