Evolve Chapter 23 Questions

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which teaching will the nurse include? a) Cover the infected area with a clean, dry bandage. b) Take daily tub baths using a mild soap. c) Wash the infected areas first, then wash the uninfected areas. d) Use bath sponges or puffs when bathing.

a) Cover the infected area with a clean, dry bandage.

Which nursing interventions can the nurse working in a long-term care facility delegate to a nursing assistant? a) Every 2 hours, reposition a client who has had a stroke and is incontinent. b) Use the Braden Scale to determine pressure injury risk for a newly admitted client. c) Complete daily sterile dressing changes for a client with a venous leg ulcer. d) Admit a newly transferred client who had pedicle flap surgery 1 week ago.

a) Every 2 hours, reposition a client who has had a stroke and is incontinent.

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication? a) Topical mupirocin b) IV vancomycin c) Oral amoxicillin d) Oral linezolid

a) Topical mupirocin

The nurse is teaching a client with loss of sensation and movement in the lower extremities secondary to spinal cord injury. Which daily prevention strategy to protect skin integrity does the nurse include in the teaching plan? a) Eat a low-fat, low-protein diet. b) Massage reddened areas several times daily. c) Lift hips off the chair at least every hour. d) Complete a pressure map to identify areas of concern.

c) Lift hips off the chair at least every hour.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include? a) "Examine your skin quarterly for lesions." b) "Avoid sun exposure between 11 a.m. and 3 p.m." c) "If you feel, you must tan, use a tanning bed." d) "Report skin changes only if a lesion gets larger."

b) "Avoid sun exposure between 11 a.m. and 3 p.m."

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? (Select all that apply.) a) "Stress can cause my flare-ups." b) "I am glad that this drug therapy will cure my condition." c) "A tanning bed will supply the ultraviolet light I need." d) "I can never be cured." e) "Medicine can prevent the growth of new skin cells."

b) "I am glad that this drug therapy will cure my condition." c) "A tanning bed will supply the ultraviolet light I need."

A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching? a) "I should cover the lesions if necessary to limit exposure to other people." b) "I may stop using the topical antibiotic when the lesions disappear." c) "I will remove crusts with soap and water before applying the medication." d) "I should contact my provider if I develop a fever or if the lesions spread.

b) "I may stop using the topical antibiotic when the lesions disappear."

Which statement by a client with psoriasis indicates that teaching by the nurse has been effective? a) "Lesions must be covered to prevent spread to my family." b) "If I plan to get pregnant while taking tazarotene, I'll talk with my provider." c) "I should be in the sunlight as much as possible for UV rays." d) "Psoriasis can be cured with steroids."

b) "If I plan to get pregnant while taking tazarotene, I'll talk with my provider."

A client has been diagnosed with tinea corporis (ringworm). To avoid spreading the infection, what does the nurse suggest? a) "No special precautions are necessary as this is not contagious." b) "Keep the site covered with a bandage." c) "Use hand sanitizer instead of soap and water to clean your hands." d) "Isolate yourself from everyone until healed."

b) "Keep the site covered with a bandage."

A client has an odorous, purulent wound, and reports feeling embarrassed. Which nursing intervention is appropriate? a) Place room deodorizers in the room. b) Change the dressing frequently. c) Suggest whirlpool therapy. d) Encourage a diet high in protein.

b) Change the dressing frequently.

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? a) Apply a barrier cream to the area. b) Clean and dry the client's skin. c) Assess the area for skin breakdown. d) Place the client in a side-lying position.

b) Clean and dry the client's skin.

A client with obesity requires frequent dressing changes for an infection on the foot. Which nursing assessment is the priority? a) Provide the necessary dressing materials. b) Determine whether the client can reach the affected area. c) Demonstrate how to change the dressing. d) Ask the client if he or she is squeamish.

b) Determine whether the client can reach the affected area.

The nurse is preparing to perform a dressing change for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. What precaution will the nurse take while performing this dressing change? a) Apply a mask. b) Don disposable gloves. c) Place soiled dressings directly in the trash. d) Use sterile technique.

b) Don disposable gloves.

A client with a foot ulcer says, "I feel helpless." What is the appropriate nursing response? (Select all that apply.) a) State,"I know how you feel." b) Encourage participation in care of the wound. c) Assure that everything will be OK. d) Suggests inviting visitors to come. e) Ask what coping strategies have worked in the past.

b) Encourage participation in care of the wound. e) Ask what coping strategies have worked in the past.

The nurse is evaluating the effectiveness of interventions for pressure injury management. Which laboratory will the nurse monitor? a) Calcium b) Serum albumin c) Numbers of immature white blood cells (WBCs) d) Hematocrit

b) Serum albumin

An older adult client who is bedridden has a documented history of protein deficiency. For which condition will the nurse monitor and attempt to prevent? a) Decreased wound healing b) Melanoma c) Pressure injury development d) Bed bugs

c) Pressure injury development

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? a) Avoiding tanning beds b) Wearing SPF 40 sunscreen c) Being aware of skin markings and performing skin self-examination d) Avoiding or reducing skin exposure to sunlight

d) Avoiding or reducing skin exposure to sunlight

The nurse observes an assistive personnel (AP) interacting with a client with a pressure injury. Which AP action requires intervention by the nurse? a) Repositions the client every 1 to 2 hours. b) Uses a moisturizing lotion on skin without pressure injuries. c) Avoids touching reddened areas. d) Massages bony prominences.

d) Massages bony prominences.