PassPoint - Integumentary

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance

The health care team is developing a care plan for a client who has burns on 30% of their body. When should the team initiate rehabilitation plans for this client?

after the client's circulatory status has been stabilized

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

behind the ears

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?

client with a compromised skin graft

The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause

diarrhea

A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body?

27%

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?

Apply a hydrocolloidal dressing.

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?

Apply direct pressure to the finger with a clean, dry cloth.

A client is experiencing intertrigo caused by friction between the inner thighs. Which action should the nurse take to help this client?

Apply lubricating lotion over the affected areas.

A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client rates the pain as 8 on a scale of 0 to 10. What should the nurse do next?

Call the health care provider (HCP) to report the loss of the radial pulse.

A client with Stevens-Johnson syndrome exhibits the following clinical manifestations. Which assessment finding requires priority action by the nurse?

oral temperature of 102.2°F (39°C)

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids.

A client has a foot ulcer that has not shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing? Select all that apply.

peripheral vascular disease diabetes

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

urine output of 20 ml/hour

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?

"Apply sunscreen even on overcast days."

Which question is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis?

"Do you have any pets?"

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?

"On the morning of the surgery, I can shave my surgical area at home to save time."

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client?

Cover the draining areas with sterile gauze.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary. This is a severe burn and nerve endings have been destroyed.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

The dressing should keep the wound moist.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should assess the client for which adverse reaction?

ototoxicity

A client is to receive biologic burn grafts. What should the nurse tell the client's family is the advantage of using biologic burn grafts such as porcine (pigskin) grafts?

promote the growth of epithelial tissue.

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias.

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. Over the past few weeks, the client has been spending less time in the wheelchair. During the appointment, the nurse notes that the client is not using a cushion and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen?

Ask the client to explain the treatment regimen.

The nurse is using home telehealth monitoring to manage care for an 80-year-old client who is homebound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. During this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) with the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit with the previous visit, the nurse should do what next?

Contact the health care provider to request a hydrocolloid dressing.

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?

Document the findings.

A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering I.V. fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse?

Ensure a fluid volume sufficient to prevent shock.

A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider?

IV rate increase

The nurse is planning care for a group of clients who are at risk for the development of pressure ulcers. What should the nurse do first?

Identify at-risk clients on admission to the health care facility.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

The nurse is assessing an 80-year-old client who has scald burns on their hands and both forearms (first- and second-degree burns on 10% of their body surface area). What should the nurse do first?

Refer the client to a burn center.

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next?

Reposition the client off the reddened skin and reassess in a few hours.

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception?

Tattoos are easily removed with laser surgery.

A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate? Select all that apply.

The ulcer is superficial, like a blister. Partial-thickness skin loss of the epidermis is evident.

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in the teaching plan?

Use a topical skin moisturizer daily.

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). What should the nurse do first?

Verify the prescription to use the restraint.

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

amount of subcutaneous tissue

The nurse is assessing a client who experienced second- and third-degree burns of the arms and hands from a kitchen grease fire. After determining that the client did not experience an inhalation injury, which assessment should be completed next?

blood pressure and heart rate

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may

dislodge the autografts.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarseness of the voice

An autograft is taken from a client's left leg. The nurse should care for the donor site by taking which action?

keeping the site clean and dry

Which nutritional deficiency may delay wound healing?

lack of vitamin C

The nurse is reviewing the intraoperative record of a client. Which information would alert the nurse to the greatest possibility of a potential for skin breakdown?

length of surgery

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

mafenide

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects

melanoma

The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder?

phenytoin

A client with atopic dermatitis is ordered a potent topical corticosteroid to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

related to percutaneous absorption of the topical corticosteroid

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority?

replacing fluid and electrolytes

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

ring or donut

During the emergency (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation?

serum creatinine level of 2.5 mg/dL (221 µmol/L)

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

small, waxy nodule with pearly borders

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

stage II pressure ulcer

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, the client's vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.

starting an I.V. infusion of lactated Ringer's solution administering 6 mg of morphine I.V. administering tetanus prophylaxis as ordered

The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot, followed by an infection. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse?

take the antibiotics until the redness goes away and my foot feels better."

The nurse is performing triage in the emergency department. Which client should be seen first?

the client with burns to the chest and neck with singed nasal hair

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?

to prevent signs of hypovolemic shock and restore circulation

The rate at which IV fluids are infused is based on the burn client's:

total body weight and BSA burned.

Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts?

use of analgesics as necessary for pain relief

The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home?

use of smoke detectors

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

"I'll eat plenty of fruits and vegetables."

A client in a semiprivate room is diagnosed with pediculosis corporis. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. How should the nurse respond?

"I'm sorry, but I can't share confidential information."

A 65-year-old client received the Zostavax vaccine for shingles 5 years ago. The client asks the nurse if the vaccine is still effective. What should the nurse tell the client?

"You should be revaccinated with a newer vaccine."