TI / Tissue Integrity

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? "A tanning bed will supply the ultraviolet light I need." "Medicine can prevent the growth of new skin cells." "I can never be cured." "Stress can cause my flare-ups."

"A tanning bed will supply the ultraviolet light I need." Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching.Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

While providing teaching to a client undergoing excisional biopsy, which statement does the nurse include? "Administration of local anesthetic agents may cause burning." "The biopsy results will be available within 2 hours of the procedure." "The dressing must remain in place for the first 48 hours." "Redness and swelling at the puncture site are expected."

"Administration of local anesthetic agents may cause burning." The nurse needs to tell the client having an excisional biopsy that local anesthetic agents may cause a burning sensation.Biopsy results are typically available 2 to 3 days, or even several weeks, after the procedure. Typically, dressings must remain in place for 8 hours, not 48 hours. Redness and swelling are unexpected after an excisional biopsy, and may be an indication of infection.

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? "The last tetanus injection was less than 5 years ago." "Burn wound conditions promote the growth of Clostridium tetani." "The wood in the fire had many nails, which penetrated the skin." "The injection was prescribed to prevent infection from Pseudomonas."

"Burn wound conditions promote the growth of Clostridium tetani." The nurse's best response is that burn wound conditions promote the growth of Clostridium tetani, and all burn clients are at risk for this dangerous infection. Tetanus toxoid enhances acquired immunity to C. tetani, so this agent is routinely given when the client is admitted to the hospital.Regardless of when the last tetanus injection is given, it is still given on admission to prevent C. tetani. The fact that there were many nails in the wood in the fire is irrelevant. Tetanus toxoid injection does not prevent Pseudomonas infection.

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? "Every bedroom should have a separate smoke detector." "Every room in the house should have a smoke detector." "If you have a smoke detector, you don't need a carbon monoxide detector." "The kitchen and the bedrooms are the only rooms that need smoke detectors."

"Every bedroom should have a separate smoke detector." The school nurse states that every bedroom needs to have a separate smoke detector. All people should be taught to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home.Every room in the house does not need a smoke detector. There should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Each room that requires a smoke detector should also have a carbon monoxide detector. Carbon monoxide detectors are instrumental in picking up carbon monoxide gas emissions, such as from a defective heating unit.

The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? "Do you support each other?" "How do you plan to manage this situation?" "How have you handled similar situations?" "Would you like to see a counselor?"

"How have you handled similar situations?" Asking how the client and family have handled similar situations in the past best assesses whether the client's and the family's coping strategies may be effective."Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage. Asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.

An older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response? "This is probably genetic" "How is this affecting you?" "Wear a hat outside to stay warm." "You could wear a wig."

"How is this affecting you?" Asking the client how she is affected best assesses the client's need for additional counseling. Open-ended questions promote good rapport between nurse and client.Telling the client that the problem is genetic is not necessarily true and does not address the impact of the problem on the client. Encouraging the client to wear a hat or a wig most likely is not what the client wants or needs to hear.

The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? "I am getting used to looking at myself." "I don't know what I will do when people stare at me." "I know that I will never look the way I used to, even after the scars heal." "My spouse does not stare at the scars as much now as in the beginning."

"I don't know what I will do when people stare at me." The statement about not knowing what to do when people stare indicates that the client is not coping effectively. The nurse needs to assist the client in exploring coping techniques. Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem.The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse does not stare at the scars as much all indicate that the client is coping effectively.

The home health nurse is doing an intake assessment on a client who had a recent punch biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? "Every morning, I check the biopsy site for signs of infection." "I have been cleaning my face with soap and water." "My appetite is improving lately." "I expect to have a permanent scar as a result of this procedure."

"I expect to have a permanent scar as a result of this procedure." The client's comment about expecting a permanent scar after a skin punch biopsy indicates the greatest need for client teaching. Punch and shave biopsies cause little or no scarring. The nurse should further assess the client for knowledge about the association between sun exposure and skin cancers and for use of sunscreens.The client should check the biopsy site daily for signs of infection. Cleaning the face with soap and water helps to prevent infection. It is normal for the client's appetite to improve.

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? "I may stop using the topical antibiotic when the lesions disappear." "I will remove crusts with soap and water before applying the medication." "I should contact my provider if I develop a fever or if the lesions spread. "I should cover the lesions if necessary to limit exposure to other people."

"I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved.Clients should be taught to remove crusts before applying the medication to improve absorption. If signs of systemic disease occur, the client should contact the provider since oral antibiotics may be necessary. Covering the lesions will help prevent spread to others.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective? "I know that I need to avoid warm climates." "I must cover up the affected areas to prevent spread to my family." "I should practice good handwashing technique." "Psoriasis can be cured with steroids."

"I should practice good handwashing technique." Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection.Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

The nurse is instructing a client about skin and sun protection. Which statement by the client indicates a need for further teaching? "I am better protected from the sun because I am dark skinned." "Sunscreen should be applied liberally." "I use a tanning bed to avoid the sun's harmful rays." "My sunglasses are UVA and UVB protected."

"I use a tanning bed to avoid the sun's harmful rays." The client stating that he or she uses a tanning bed indicates that the client needs further teaching. Tanning beds are just as damaging to the skin as the sun's rays.Dark-skinned people are better protected from the sun than light-skinned people. Regular use of sunscreen helps protect skin from the sun. Sunglasses with UVA- and UVB-protected lenses help shield the eyes from the sun's harmful rays.

A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother? "Wash your hands frequently." "Your child may return to school, but must be isolated from the rest of the class." "Keep the site covered with a bandage." "Keep your child out of school until the infection has cleared."

"Keep the site covered with a bandage." Keeping the site covered with a bandage prevents spread of the infection.Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? "Do you want to pray about it?" "I know, and you will have to learn to adapt to a new body image." "Tell me more." "There must be a reason."

"Tell me more." Asking the client to tell the nurse more best encourages therapeutic grieving.Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving. The nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason," minimizes the grieving process by not allowing the client to express his or her concerns.

When the nurse is assessing the skin of an older adult client, which of these findings will be most important to report to the health care provider (HCP)? A multicolored lesion is present on the client's thigh. Liver spots are present on both hands. Cherry hemangiomas are scattered on the client's back. The skin on the extremities is paper-thin.

A multicolored lesion is present on the client's thigh. The most important skin assessment finding to report to the HCP is the presence of a multicolored lesion on the client's thigh. Color variation within a lesion is associated with skin cancer; the health care provider should be informed so that the lesion can be further assessed.Liver spots, cherry hemangiomas, and loss of skin elasticity are findings that are associated with aging and are normal for an older adult.

Which activity for a long-term-care client does the nurse plan to assign to the LPN/LVN? Develop a care plan for a client who has blisters caused by herpes zoster. Administer an antihistamine to a client who is describing pruritus. Teach a client how to self-assess for changes in skin lesions. Perform a baseline skin assessment for a newly admitted client.

Administer an antihistamine to a client who is describing pruritus. LPN/LVNs are familiar with safe administration of medications, including monitoring for medication effectiveness and adverse effects.Developing care plans and client assessment requires more critical judgment and education and should be done by an RN. Providing client instruction is a more complex skill that is included in the RN scope of practice.

The nurse is reviewing the orders for a child with cellulitis. What would the nurse expect to see ordered for this patient? Damp to dry compresses using Burow's solution Administration of oral or parenteral antibiotics for several days Topical application of an antibiotic cream to the involved area Incision and drainage of cellulitis lesions covering a wide area

Administration of oral or parenteral antibiotics for several days Oral or parenteral antibiotics are indicated because of the need to have the antibiotic infused systemically. The antibiotic needs to be administered systemically. Incision and drainage of severe cellulitis lesions is done only if it is determined that the cellulitis is localized enough. If this is done, there is a risk of spreading infection or making the lesion worse. Warmed sterile water or sterile saline dressings may be indicated for limited cellulitis.

The staff mix available for the medical-surgical unit includes RNs, LPN/LVNs, and nursing assistants. Which client does the nurse plan to assign to an experienced LPN/LVN? Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road Adult client who needs to be admitted for grafting of a second-degree burn on the right leg Middle-aged adult client who needs discharge teaching before going home after receiving steroids for Stevens-Johnson syndrome Older adult client with stage I pressure ulcers who needs to be turned every 2 hours

Adult client who has had suturing of a facial tear that occurred when the client fell off a bike onto a dirt road An LPN/LVN would be appropriate to care for an adult client with a facial suture. This nurse would be familiar with wound monitoring for potentially contaminated wounds and would recognize the manifestations of infection.Conducting an admission assessment and discharge teaching is more complex nursing actions that require RN-level education and scope of practice. The older adult with stage I pressure ulcers who needs to be turned every 2 hours could be cared for by a nursing assistant.

A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity does the nurse assign to an LPN/LVN working with this client? Teach the client about signs of incisional infection. Instruct the client about how to do dressing changes. Apply an antibiotic ointment and place a sterile dressing on the incision. Complete the written discharge instructions for the long-term-care facility.

Apply an antibiotic ointment and place a sterile dressing on the incision. Wound care is included in practical nursing education.Client teaching and instruction and completing discharge teaching are more complex skills that are included in the RN scope of practice.

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? Select all that apply. Applying over-the-counter lotions to skin that is not broken Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage Assessing a patient complaining of an itching rash

Applying over-the-counter lotions to skin that is not broken Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

Which method does the nurse use to assess skin lesions for cancer? Presence of inflammation or exudate Asymmetry, border, color, diameter, evolving Wood's light examination for fluorescence Size and location of lesions

Asymmetry, border, color, diameter, evolving The ABCDE (asymmetry, border, color, diameter, evolving) method is the accepted technique for assessing skin lesions.Inflammation and exudate indicate infection. A Wood's light examination is used to assess for fungal infections. Size and location of lesions is not specific for cancer screening.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include? "Avoid sun exposure between 11 a.m. and 3 p.m." "Examine your skin quarterly for possible cancerous or precancerous lesions." "Keep a total body spot and lesion map." "If you feel you must tan, use a tanning bed."

Avoid sun exposure between 11 a.m. and 3 p.m." The nurse teaches the client that the sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time.Skin should be examined at least monthly. A total body spot and lesion map is used for secondary prevention. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

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? Avoiding or reducing skin exposure to sunlight Avoiding tanning beds Being aware of skin markings and performing skin self-examination Wearing SPF 40 sunscreen

Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily.Avoiding tanning beds is significant, but is not the most important technique. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term-care client who has areas of skin breakdown in the skinfolds and the perineal area. Which intervention is best for the RN to delegate to the nursing assistant? Check the client's skin weekly for areas of redness or breakdown. Teach the client and family about the importance of good hygiene in skinfolds. Evaluate the client's ability to provide skin hygiene independently. Bathe the client, and apply a protective barrier to skinfolds and perineum.

Bathe the client, and apply a protective barrier to skinfolds and perineum. Assisting clients with bathing and personal hygiene is included in nursing assistant education.Assessment, teaching, and evaluation are more complex, higher-level skills that require the education and scope of practice of licensed nursing staff.

The pediatric office nurse is giving instructions to a parent whose child has scabies. What information should the school nurse include? Treat all of the family members if symptoms develop. Be prepared for symptoms to last 2 to 3 weeks. Notify your health care practitioner so an antibiotic can be prescribed. Carefully treat only those areas where there is a rash.

Be prepared for symptoms to last 2 to 3 weeks. The mite responsible for the scabies will most likely be killed with the administration of medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the symptoms will abate. A scabicide is used. Permethrin (Nix) and Lindane (Kwell) are currently used for topical administration. Permethrin (Nix) is applied to all skin surfaces. Only the affected individuals need to be treated.

The nurse is teaching a client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client? Body image counseling Respiratory protection Self-suctioning Tobacco cessation education

Body image counseling Damage to the epidermis (the outer layer of the skin) can cause body image disturbance for clients. The nurse needs to include body image counseling when discussing this topic with the client.Respiratory protection, self-suctioning, and tobacco cessation education are not related to damage to the epidermis.

A group of teenage boys have just gotten on the basketball team and will be showering in the school's locker room after practice. What suggestions should the school nurse provide to these adolescents to decrease the chance of contracting athlete's foot (tinea pedis)? Select all that apply. Bring your own soap and towel, and don't share them with others. Dry your feet completely. Wear your practice shoes home. Change your socks every other day when not practicing. Use talcum powder or antifungal powder to keep your feet dry. Make sure your shoes are thoroughly dry before wearing them.

Bring your own soap and towel, and don't share them with others. Dry your feet completely. Use talcum powder or antifungal powder to keep your feet dry. Make sure your shoes are thoroughly dry before wearing them.

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? Apply a barrier cream to the area. Assess the area for skin breakdown. Clean and dry the client's skin. Place the client in a side-lying position.

Clean and dry the client's skin. Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection.Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.

An occlusive dressing, Acu-Derm, is applied to a large abrasion. What is the reason the nurse would use this type of dressing? It delivers vitamin C to the wound. It provides an antiseptic for the wound. It promotes mechanical friction for healing. It maintains a moist environment for healing.

It maintains a moist environment for healing. Occlusive dressings, such as Acu-Derm, provide a dressing that is non-adherent to the wound site. It provides a moist wound surface and insulates the wound. The dressing does not have vitamin C, does not have antiseptic capabilities, and protects against friction.

A client has an odorous, purulent wound. How does the nurse best support this client? Changes the dressing frequently Encourages a diet high in protein Suggests whirlpool therapy Places room deodorizers in the room

Changes the dressing frequently The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the best method of support for this client.A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

The nurse notices yellowing at the corners of the sclera in an African-American client admitted for hepatitis. What does the nurse do next? Palpate the liver. Check the oral mucosa. Examine the client's hair. Monitor pulse oximetry.

Check the oral mucosa. After assessing an African-American client's sclera for jaundice, the nurse would next check for a yellow tinge to the oral mucous membranes, especially the hard palate. The nurse would then examine the sclera nearest to the iris rather than the corners of the eye.Although the liver is involved in hepatitis, palpating it is not the nurse's next action. Examining the hair and monitoring pulse oximetry are not indicated for this client.

The nurse is teaching adolescents about the management of acne. What should the nurse include in the discussion? Clean the face with an antibacterial soap twice each day. Clean the face gently with a mild soap once or twice each day. Avoid foods with a high fat content, such as French fries and chocolate. Express comedones by gentle squeezing; then cleanse with alcohol.

Clean the face gently with a mild soap once or twice each day. Cleansing the face with mild soap and water will remove surface dirt and oil. No relationship has been established between food intake and acne. Squeezing comedones and then cleansing with alcohol can break down the ductal walls of the lesions and cause the acne to worsen. Antibacterial soaps may be too drying when used in combination with topical medications.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? Select all that apply. Cleansing the wound Managing pain Applying a dry sterile dressing Using cold water in the bath

Cleansing the wound Managing pain Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? Burn unit client who is being discharged after 6 weeks and needs teaching about wound care Recently admitted client with a high-voltage electrical burn A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed Client receiving IV lactated Ringer's solution at 150 mL/hr

Client receiving IV lactated Ringer's solution at 150 mL/hr An RN float nurse from ICU will be familiar with administration of IV fluids and with signs of fluid overload, such as shortness of breath, and so could be assigned to the client receiving IV lactated Ringer's solution at 150 mL/hr.The client needing teaching about wound care, the client with a high-voltage electrical burn, and the client with a 25% TBSA burn injury all require specialized knowledge about burn injuries and should be assigned to RNs who have experience caring for clients with burn injuries.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan? Take daily tub baths using a mild soap. Cover the infected area with a clean, dry bandage. Wash the infected areas first, then wash the uninfected areas. Use bath sponges or puffs when bathing.

Cover the infected area with a clean, dry bandage. The nurse includes the instruction that the infected area should be covered with a clean, dry bandage to prevent the spread of infection.The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? Encouraging participation in wound care Encouraging visitors Reassuring the client that he or she will be fine Telling the client that these feelings are normal

Encouraging participation in wound care. Encouraging participation in wound care is most helpful in providing the client some sense of control.Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.

Which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? 1-mm ecchymotic area on the upper extremity Presence of one of the "ABCDE" features Dark red color Round and raised appearance

Presence of one of the "ABCDE" features A lesion with one or more of the ABCDE (asymmetry, border irregularity, color variation, diameter, evolving) features should be evaluated by a dermatologist or a surgeon.Ecchymosis is a bruise and is not necessarily problematic; it is common after minor trauma. A dark red color or a round and raised appearance is not necessarily problematic.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for? Anemia Decreased wound healing Pressure ulcer development Weight gain

Pressure ulcer development This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden.Anemia and weight gain have no correlation with this client's protein deficiency. The client does not have an indicated wound.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? Asks the client if he is squeamish Demonstrates how to change the dressing Determines whether the client can reach the affected area Provides all of the necessary dressing materials

Determines whether the client can reach the affected area Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home.The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

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

Lift hips off the chair at least every hour. The daily prevention strategy the nurse includes in the client's teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure ulcers.Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.

Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound Tachycardia

Dry, crusty granulation tissue Edema of the skin around the wound Tachycardia Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection.Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? Encourages participation in care of the wound Encourages visitors Says, "I know how you feel" Assures the client that it will be all right

Encourages participation in care of the wound The nurse's best response is to encourage client participation in wound care. This gives the client a sense of autonomy.Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.

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

Every 2 hours, reposition a client who has had a stroke and is incontinent. The nurse can delegate repositioning a client to a nursing assistant. A nursing assistant has the education and scope of practice to perform such a task.Using the Braden Scale, changing a sterile dressing, and client admissions are actions that should be done by licensed nursing staff who have broader education and scope of practice.

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" The nurse first needs to assess the firefighter recently admitted with smoke inhalation. Smoke inhalation and facial burns are associated with airway inflammation and obstruction. The client with difficulty breathing needs immediate assessment and intervention.Although the client admitted a week ago with deep partial-thickness burns is reporting pain, this client does not require immediate assessment. The electrician who suffered burn injuries a month ago is stable and has been in the burn unit for a month, so the client's condition does not warrant that the nurse should assess this client first. The older adult client admitted yesterday with burns over 40% of the body is stable; he is receiving IV fluids and does not need to be assessed first.

Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? Clustered round lesions to the chest Five clustered circumscribed lesions on the chest Five diffuse circinate lesions on the chest Several lesions in one area that have well-defined borders

Five clustered circumscribed lesions on the chest "Five clustered circumscribed lesions on the chest" is specific, with correct terminology."Clustered round lesions to the chest" and "five diffuse circinate lesions on the chest" use incorrect terminology. "Several lesions in one area that have well-defined borders" is too vague to describe the condition accurately.

A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? Range-of-motion exercises Emotional support Fluid resuscitation Sterile dressing changes

Fluid resuscitation During the first 24 hours after a burn injury, the nurse's first priority is to administer fluid resuscitation because fluid does not stay in the vessels after a burn injury.Range-of-motion exercise is not the priority for this client. Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.

An older, immobile client has slipped to the bottom of the bed. What does the nurse do first? Gently pull the client up. Get help and lift the client. Look for broken skin areas. Pad the bony prominences.

Get help and lift the client. The first action by the nurse would be to get help and gently lift the client with a sheet.Pulling or dragging the client should be avoided. Looking for broken skin areas or padding bony prominences is not the priority.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? Give oxygen per facemask. Infuse lactated Ringer's solution at 150 mL/hr. Give morphine sulfate 4 to 10 mg IV for pain control. Insert a 14 Fr retention catheter.

Give oxygen per facemask. The nurse needs to first administer oxygen per face mask to the client. Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level.Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? Pale, boggy, dry, or crusted granulation tissue Increasing wound drainage Scar tissue formation Sloughing of grafts

Scar tissue formation Indicators of wound healing include the presence of granulation, reepithelialization, and scar tissue formation.Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? Heart failure Diverticulitis Hypertension Emphysema

Heart failure The nurse will contact the health care provider if the client's history reveals specific information about cardiac or kidney problems, chronic alcoholism, substance abuse, or diabetes mellitus. Any of these problems can influence fluid resuscitation. A client's health history, including any preexisting illnesses, must be known for appropriate management. The stress of a burn injury can make a mild disease process worsen. In older clients, especially those with cardiac disease, a complicating factor in fluid resuscitation may be heart failure or myocardial infarction.Diverticulitis, hypertension, and emphysema are important to be aware of in guiding treatment options. However, heart failure is the main concern when attempting to optimize this older client's fluid resuscitation.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? Hyperbaric oxygen Nutrition therapy Topical growth factors Vacuum-assisted wound closure

Hyperbaric oxygen Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically débrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? Intense pain Potential for inadequate oxygenation Impaired self-image Potential for infection

Impaired self-image A priority problem of impaired self-image is expected during the rehabilitation phase. During this phase, the client is discharged and his or her life is not the same.A priority problem of impaired self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? In a neutral position In a position of comfort Slightly flexed Slightly hyperextended

In a neutral position The neutral (extended) position is the correct placement of the elbow to prevent contracture development.Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? Intramuscular Intravenous Sublingual Topical

Intravenous During the resuscitation phase, the intravenous (IV) route is used for giving opioid drugs because of problems with absorption from the muscle and stomach.When these agents (opioid drugs) are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.

The school nurse is educating a group of elementary school teachers about ringworm (tinea capitis). Which explanation of the condition by the nurse is best? It is self-limiting and not contagious. It is a sign of uncleanliness. The patient should recover spontaneously without interventions. It is spread by direct and indirect contact.

It is spread by direct and indirect contact. Ringworm is spread by both direct and indirect contact. Children should wear protective caps at night to avoid transfer of ringworm to bedding. Ringworm is infectious and not self-limiting. Because ringworm is easily transmitted, it is not a sign of uncleanliness. It can be transmitted by theater seats, gym mats, and animal-to-human transmission. Treatment is required with the drug griseofulvin (Grisactin), which is indicated for a prolonged course, possibly several months

The RN is performing an assessment on an older adult client who is in congestive heart failure. Which skin finding during palpation of the extremities is the nurse specifically concerned about? Slight tears on the forearms Fairly widespread dry flakiness Several smaller bruises on the extremities Marked dependent pitting edema

Marked dependent pitting edema Dependent pitting edema may indicate venous and cardiac insufficiency in clients with congestive heart failure.Skin tears may occur where adhesive tapes or dressings have been applied and removed, especially in older clients with fragile skin. Dry skin usually has scaling and flaking, and may be especially marked in areas of limited circulation such as the feet and lower legs. It is a common problem during the winter months when the air contains less moisture, in geographic areas with little humidity, and in the hospital environment where humidity is often low. In older adults, bruising is common after minor trauma to the skin.

The nursing instructor reviews instructions with the nursing student about caring for an older adult client with a pressure ulcer. What action by the nursing student indicates a need for further instruction about proper skin care for this client? Massages bony prominences Avoids reddened areas Repositions the client every 1 to 2 hours Uses a moisturizing lotion

Massages bony prominences Massaging bony prominences should be avoided in older adult clients because they are at high risk for skin tears. The nursing instructor needs to make sure that the student is aware of this fact.Reddened areas should not be directly massaged because this can damage capillary beds and increase tissue necrosis. The client should be repositioned at least every 1 to 2 hours to prevent ulcer extension and the generation of additional pressure ulcers. Using a moisturizing lotion is appropriate.

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions? Select all that apply. Bathe and dry the skin vigorously to stimulate circulation. Keep the head of the bed elevated 30 degrees. Offer nutritional supplements and frequent snacks. Turn the patient at least every 2 hours. Maintain a cooler environment when bathing.

Offer nutritional supplements and frequent snacks. Turn the patient at least every 2 hours.

The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments? Select all that apply. Oral steroids Topical steroids Oral antihistamines Topical antihistamines Topical petroleum ointment

Oral steroids Topical steroids Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? Black-brown coloration Painful blisters Moderate to severe edema Absence of blisters

Painful blisters Characteristics of a superficial partial-thickness burn injury include pink to red coloration, mild to moderate edema, pain, and blisters.A black-brown coloration is more suggestive of full-thickness burn injury. Moderate to severe edema and absence of blisters may be present with deep partial-thickness to full-thickness burn injuries.

A client has had a melanoma lesion removed. For secondary prevention, what is most important for the nurse to teach the client? Ensure that all lesions are reviewed by a dermatologist or a surgeon. Avoid sun exposure. Have any new lesions genetically tested. Perform a total skin self-examination monthly with a partner.

Perform a total skin self-examination monthly with a partner. The nurse teaches the client that performing a monthly total skin self-examination with another person is the best secondary preventive measure.If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. Genetic testing of lesions is performed to determine whether targeted therapy will be effective.

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. Provides cushions for comfort Performs frequent handwashing Places plants in the client's room Performs gloved dressing changes Uses disposable dishes

Performs frequent handwashing Performs gloved dressing changes Uses disposable dishes Frequent handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible.Cushions are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

Which skin condition will the emergency department nurse assess first? Localized redness of a surgical site Pitting edema Poor skin turgor Red bony prominences

Pitting edema Pitting edema indicates an electrolyte, cardiac, or renal insufficiency and is the emergency nurse's first priority.Localized redness of the surgical site is the body's normal response to trauma. Poor skin turgor is not an urgent finding and may be caused by age or dehydration. Bony prominences that are red are an important finding, but are not the first priority in this situation.

The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action does the nurse take first? Add potassium hydroxide to the specimen to check for a possible fungal infection and inspect it under the microscope. Soak the crust of a possible bacterial lesion with normal saline. Instruct the client who has had a punch biopsy about wound care. Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.

Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory. To obtain accurate results for clients with possible herpes zoster infections, the nurse needs to first place viral cultures, on ice and then transport them to the laboratory.Adding potassium hydroxide to the specimen to check for a possible fungal infection before inspecting it under the microscope, soaking the crust of a possible bacterial lesion with normal saline, and instructing the client about wound care do not require immediate action.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? Discouraging having food brought in from the client's favorite restaurant Providing more palatable choices for the client Helping the client maintain a desirable weight Planning additions to the standard nutritional pattern

Planning additions to the standard nutritional pattern Consultation with the dietitian is required to help the client achieve the correct nutritional balance. Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing.It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.

The nurse is applying wet dressings on the skin. What procedure would be correct for the nurse to use? Apply the dressing when it is saturated and dripping. Apply the dressing so that the area is totally immobilized. Pour new solution over a dressing that has become dry, or apply solution with a syringe. Pour the desired solution on soft gauze and then squeeze the gauze to remove excess liquid prior to putting it on the skin.

Pour the desired solution on soft gauze and then squeeze the gauze to remove excess liquid prior to putting it on the skin.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? Massage the reddened areas. Pad the ulcer. Promote mobility and/or frequent repositioning. Suggest an egg crate mattress.

Promote mobility and/or frequent repositioning. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.

The nurse observes multiple small pits in all of a client's fingernails. The nurse suspects that the client may have which condition? Cystic fibrosis Iron deficiency anemia Isolated periods of severe malnutrition Psoriasis

Psoriasis Pitting of the fingernails may be seen in clients with psoriasis and alopecia areata. It can involve several or all of the fingernails and also be associated with plate thickening and onycholysis.Late clubbing of the fingernails is a sign of cystic fibrosis. Spoon nails (koilonychias) are a sign of iron deficiency anemia. Beau's grooves are a sign of isolated periods of severe malnutrition.

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? First Second Third Mixed

Second Second-intention healing is characterized by a cavitylike defect frequently found in chronic pressure ulcers. This involves gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss.First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Red and white wounds with mild pain to palpation Painless, brownish yellow eschar Painful reddened blisters Black skin with eschar and no pain

Red and white wounds with mild pain to palpation A red and white wound bed characterizes deep partial-thickness burns. Blisters are rare. Pain is less than with other types of burns because nerve endings are affected.Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn. Painless black skin with eschar is seen in a deep full-thickness burn

During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response? Clubbing of the nail beds Cool extremities Erythema at the incision site Reddish blue area on the calf

Reddish blue area on the calf A reddish blue area on the calf is indicative of decreased tissue perfusion and requires urgent attention.Clubbing of the nail beds is a chronic symptom, not a postoperative concern. Cool extremities are a normal postoperative occurrence. Erythema is expected at the incision site and does not warrant an urgent response.

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? Reduction of bacterial growth in the wound and prevention of systemic sepsis Prevention of cross-contamination from other clients in the unit Enhanced cell growth Reduced need for a skin graft

Reduction of bacterial growth in the wound and prevention of systemic sepsis The best description of the goal of topical antimicrobials such as silver sulfadiazine is that they help prevent infection in burn wounds.Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

The school nurse is seeing a child who brought poison ivy to school in his leaf collection. The child says, "It only touched my hands." What is the initial nursing action? Apply compresses using Burow's solution. Soak the child's hands in warm water. Rinse the child's hands in cold, running water. Scrub the child's hands thoroughly with antibacterial soap.

Rinse the child's hands in cold, running water. Rinsing the child's hands in cold, running water is the recommended first action. Once contact has been made, it is desirable to flush the skin with cold, running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. The antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread. Application of Burow's solution compresses is effective for soothing the skin lesions once the dermatitis has begun. Cold, running water, not warm, is effective in removing the oil.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration? Calcium Hematocrit Numbers of immature white blood cells (WBCs) Serum albumin

Serum albumin Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? Bowel sounds Muscle strength Signs of infection Urine output

Signs of infection The client with burn injury is at highest risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery.Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

The nurse is caring for a 12-year-old boy who sustained major burns when putting charcoal lighter on a campfire. The nurse observes that boy is "very brave" and appears to accept pain with little or no response. Based on the nurse's knowledge of burns, pain, and age-specific development, what is the most appropriate nursing action? Talk with the health care provider about the possibility of requesting a psychological consultation. Spend time with the child to better understand why he doesn't seem to respond to pain. Praise the child frequently for his ability to deal with the pain. Encourage continued bravery as a coping strategy.

Talk with the health care provider about the possibility of requesting a psychological consultation. A psychological consultation will assist the child to verbalize fears. This age group is concerned with physical appearance. The psychologists can help integrate the issues that the child is facing. The nurse would talk with the health care provider and share the observations about this child, but ultimately the health care provider would be the one to decide if a consult is warranted. Further assessment is needed, but this child would probably benefit from the psychologist. It is likely that the child is having pain but not acknowledging it. If the child is feeling pain, the nurse should not praise him for hiding it. The nurse must act as an advocate and keep the child as comfortable as possible. Encouraging bravery may not be an effective coping strategy if the child is in severe pain.

The nurse is caring for an infant with recurrent atopic dermatitis (eczema). What information would the nurse expect to see in the infant's history? It last happened in the summer. The infant recently traveled to a humid climate. The infant has several allergies similar to her mother. The infant had an upper respiratory infection a week ago.

The infant has several allergies similar to her mother. The majority of children with atopic dermatitis have a family history of eczema, asthma, food allergies, or allergic rhinitis. This suggests a genetic predisposition. It is associated with allergies and not upper respiratory infections. Atopic dermatitis worsens in fall and winter. It improves in humid climates.

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? Bowel sounds are absent. The pulse oximetry level is 91%. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). Urine output since admission is 370 mL.

The serum potassium level is 6.1 mEq/L (6.1 mmol/L). The greatest concern for the nurse is to notice an elevated serum potassium level that can cause cardiac dysrhythmias and arrest.Absence of bowel sounds, a pulse oximetry level of 91%, and urine output of 370 mL since admission are normal findings during the resuscitation phase of burn injury.

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? Administer a diuretic. Provide a fluid bolus. Recalculate fluid replacement based on time of hospital arrival. Titrate fluid replacement.

Titrate fluid replacement. The nurse first needs to adjust and titrate the intravenous fluid rate on the basis of urine output plus serum electrolyte values.A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.

During the rehabilitative phase of care, the nurse applies pressure dressings to the patient's severely burned areas. This activity is used to accomplish which goal? To relieve as much pain as possible To decrease the development of scar tissue To promote motion during the healing process To protect underlying tissue by encouraging scar formation

To decrease the development of scar tissue Uniform pressure to the scar decreases blood supply. The use of pressure garments serves to decrease the blood supply to the hypertrophic tissue. This is done to prevent scarring and contractures. Motion is encouraged because it prevents contractures, but this has nothing to do with the pressure dressing application. The goal of the pressure dressing is to minimize the development of scar tissue. The goal of the pressure dressing is to improve the appearance of scars.

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? Oral amoxicillin Oral linezolid Topical mupirocin IV vancomycin

Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy.Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe.

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) Creatinine, 2.8 mg/dL (248 mcmol/L) Urine output, 40 mL/hr Urine specific gravity, 1.042

Urine output, 40 mL/hr Clinical improvement based on fluid resuscitation for a burn client correlates with a urine output of between 30 and 50 mL/hr or 0.5 mL/kg/hr.A BUN of 36 mg/dL (12.9 mmol/L) is above normal, a creatinine of 2.8 mg/dL (248 mcmol/L) is above normal, and a urine specific gravity of 1.042 is above normal.

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? Select all that apply. Wear sunglasses. Drink plenty of water. Eat plenty of foods high in vitamin K. Apply sunscreen 30 minutes prior to exposure. Consume fish oil and vitamin E.

Wear sunglasses. Apply sunscreen 30 minutes prior to exposure. Consume fish oil and vitamin E. Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

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? Wearing disposable gloves Wearing a mask Using sterile technique Placing soiled dressings in the trash

Wearing disposable gloves The nurse will wear disposable gloves. Disposable gloves are necessary when changing a dressing on a wound infected with MRSA to prevent transmission to others.It is not necessary to wear a mask, since the infection is spread by direct contact with the infected material. Sterile technique is not indicated. Soiled dressings should be placed in a sealed plastic bag before discarding, and according to agency policy.

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? Middle-aged adult who is frantically explaining to the nurse what happened Young adult who suffered burn injuries in a closed space Adult with burns to the extremities Older adult with thick, tan-colored sputum

Young adult who suffered burn injuries in a closed space The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke.Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

The parents of a young boy with burns covering 40% of the total body surface area (TBSA) ask why he is receiving enteral feedings at night while he is sleeping and is eating during the day. Which response by the nurse is best? "His appetite is really poor right now and he needs more fluid." "Your son needs more protein and calories than he can eat while awake." "Your child needs a large quantity of high carbohydrate and low protein." "His intestinal activity is slow right now, and this is easier on his system."

Your son needs more protein and calories than he can eat while awake." Enteral feedings can supply the protein, carbohydrate, and calories that the child cannot ingest. The feedings are stopped during the day so the child is able to eat basically whatever he wants, and then the minimum amount of nutrition can be ensured by the enteral feedings at night. A diet high in protein, carbohydrate, and calories is recommended. The combination of eating and enteral feedings allows the child to eat "kid food" during the day and receive the nutrients he needs at night. The hourly amount of the enteral feeding will also depend on how the child tolerates the feeding. It is often true that appetites are diminished because of pain. Oral feedings are not contraindicated. This is encouraged; however, most children with burns are unable to consume sufficient calories by mouth.

What is the best method to prevent autocontamination for a client with burns? a. Change gloves when handling wounds on different areas of the body. b. Ensure that the client is in isolation therapy. c. Restrict visitors. d. Use sterile gloves when changing dressings.

a. Change gloves when handling wounds on different areas of the body. The best way to prevent autocontamination for a burn client is to change gloves when performing wound care on different areas of the body.Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Using sterile versus clean gloves is a matter of institutional preference and a topic of debate.