ATI NURS 1200 Week 5

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

Nausea and vomiting Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness , and confusion

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following actions are appropriate? (select all that apply)

use pillows to keep heels off the bed surface minimize skin exposure

A nurse is caring for an adult client who has atopic dermatitis. Which of the following findings should the nurse expect?

A chronic rash with thick skin. A topic dermatitis is a chronic rash. A classic sign in the adult client is lichenification (thick, "leathery" skin)

A nurse is assessing a client who has peripheral IV with continuous infusion. Which of the following findings is a manifestation of phelebitis?

Throbbing erythema warmth at the insertion site streak formation

A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion side?

"The area surrounding the insertion site feels warm to the touch"

A nurse is performing in integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? A. Painless, raised purple nodules on the hard palate B. A firm nodule with a hard crust C. A small macule with a yellow-brown scale D. Yellow-white patches of growth on the tongue

A firm nodule with a hard crust

A nurse in a long-term care facility is caring for an older adult client who has had a stroke four weeks ago and he was unable to move independently. The nurse should monitor for which of the following complications of immobility? A. I read an area over the sacrum B. stiffness in the lower extremities. C. Difficulty moving the upper extremities. D. Difficulty hearing some types of sounds.

A reddened area over the sacrum. A reddened area over bony prominence is a stage one pressure ulcer, a complication of immobility. The nurse recognizes at this stage and implement measures to avoid additional pressure, it might not progress to the next stage

A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?

A small, translucent papule with rolled borders.

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the clients plan of care?

Auscultate breath sounds at every 2 hours. The party action of the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the clients need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.

A nurse is providing discharge teaching to a client following an excisional biopsy of a skin lesion. Which of the following information should the nurse include in the teaching. Keep the dressing in place for at least 24 hours. Clean incisional site daily after the dressing is removed. Use hydrogen peroxide to clean the incisional site. The sutures will be removed in two weeks.

Clean incisional site daily after the dressing is removed.

A nurse is teaching a client who has a new prescription for a topical betamethaone to treat contact dermatitis. Which of the following instruction should the nurse include? A. "Cover areas of excoriated skin with cream" B. "use hot water to soothe the lesions." C. "covered area with an occlusive dressing after application." D. "use the cream for a few days after the area has healed."

D. "use the cream for a few days after the area has healed." The client to continue to apply steroid cream to affected area for a few days after the areas healed to reduce the risk of reoccurrence

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply)

Minimize skin exposure to moisture Use pillows to keep heels off the bed surface.

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings as a manifestation of stage 3 pressure ulcer.

Necrotic subcutaneous tissue. Manifestations of a stage three pressure ulcer include full thickness skin loss with necrotic subcutaneous tissue

A nurse is caring for an older client who is at risk for skin breakdown. Which of the following intervention should the nurse use to help maintain the integrity of the client skin?

Provide the client with a diet high in protein. In adequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse is caring for a client who has contact dermatologist of the neck and upper chest. Which of the following is an expected finding? A. Report of exposure to a skin irritant. B. Denial of pruritus. C. Systematic symptoms including elevated temperature. D. Report of generalized joint discomfort

Report of exposure to a skin irritant. The most common cause of contact Irma Titus as exposure to a topical irritant therefore identifying this irritant as a component of treatment

A nurse is developing a plan of care for a client who has a stage three pressure ulcer. Which of the following intervention should the nurse include in the plan?

Reposition the client at least every two hours. The nurse should plan to reposition the client list every two hours and make a schedule to record position changes for the clients medical record.

A nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect

Scaling and redness between the toes are expected findings of tinea pedis, which is commonly called athlete's foot.

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressing should the nurse plan to apply?

Transparent Dressing Stage one pressure ulcer involves only the epidermal skin. Transparent dressing protects the ulcer from moisture and bacteria while on oxygen to reach the skin. Distressing also minimize friction and shear on the ulcerated area.

A nurse is planning care for an older adult client who is at risk of developing pressure ulcers. Which of the following intervention should the nurse use to maintain the integrity of the client skin?

Use a transfer device to let the client up in bed. Do you think I lived in a vase prevents dragging the client skin across the bed linens, which can cause abrasions.

A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide?A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide?

Wash the affected area with soap and water before applying cream. The client should watch the affected area of southern water and dry it thoroughly before applying the cream.