The nurse recognizes that skin integrity can be compromised by being e

The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to:

1. Urine
2. Purulent exudates
3. Pancreatic fluids
4. Serosanguineous drainage

ANSWER

ANS: 3
Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Exposure to urine, bile, stool, acetic fluid, and purulent wound exudates carries a moderate risk for skin breakdown. Serosanguineous drainage is not caustic to the skin, and the risk for skin breakdown from exposure to this fluid is low.