RNSG 1128 Dr. Miles

What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings? A. Change position at least once each shift. B. Implement a turning schedule every 2 hours. C. Use ring cushions for heels and elbows. D. Do not turn, use pressure-relieving support surface.

A. Change position at least once each shift.

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? a. Serous b. Sanguineous c. Serosanguineous d. Purulent

Serosanguineous The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands? a). Dermis b. Epidermis c. Subcutaneous Layer d. Connective Layer

a). Dermis The dermis might be considered the "core" of the integumentary system (derma- = "skin"), as distinct from the epidermis (epi- = "upon" or "over") and hypodermis (hypo- = "below"). It contains blood and lymph vessels, nerves, and other structures, such as hair follicles and sweat glands.

The skin assessment of a black client reveals the presence of white areas on the skin that are flat, nonpalpable, less than 1 cm in diameter, and have a circumscribed border. How does the nurse document the finding?a. Macule b. Melasma c. Erosion d.. Petechia

a. Macule

An 81-year-old woman has noted a gradual decrease in the moisture of her skin over many years. Which phenomena associated with the aging process are known to contribute to her xerosis? Select all that apply. a. Separation of the basement membrane from adjacent dermal and epidermal layers b. Changing composition of sebaceous gland secretions c. Flattening of the dermal rete ridges d. Decreased moisture secretions from sweat glands e. Decrease in skin capillariesDescribe

b. Changing composition of sebaceous gland secretions c. Flattening of the dermal rete ridges e. Decrease in skin capillaries

Which of the following are functions of the skin? Select all that apply. a. Protection b. Temperature regulation c. Sensation d. Vitamin C production e. Immunological

b. Temperature regulation a. Protection e. Immunological c. Sensation

the nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means? a) Second intention b)Late intention c)Third intention d)First intention

c)Third intention

A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information? a. "I will drink a lot of orange juice and drink milk too." b. "I will take the zinc supplement the doctor recommended." c. "I will restrict my diet to fats and carbohydrates." d. "I will drink 8 to 10 glasses of water every day."

c. "I will restrict my diet to fats and carbohydrates."

Which statement best conveys an aspect of the process of keratinization? a. Keratin cells synthesized in the dermis migrate to the surface over 20 to 30 days. b. Mitosis that begins with the cells of the stratum granulosum results in a continual supply of new keratinocytes. c. The stratum germinativum continuously produces new keratinocytes to replace losses. d. The basal cells of the epidermis migrate to the skin surface at a rate that matches superficial losses of skin cells.

c. The stratum germinativum continuously produces new keratinocytes to replace losses.

What are the two major processes involved in the inflammatory phase of wound healing? a. bleeding is stimulated, epithelial cells are deposited b. granulation tissue is formed, collagen is deposited c. collagen is remodeled, avascular scar forms d. blood clotting is initiated, WBCs move into the wound

d. blood clotting is initiated, WBCs move into the wound