Adult Integumentary Saunders

The nurse is assigned to care for a client with a leg ulcer. Sutilains treatments are prescribed. The nurse would avoid which action when performing the treatment?

Applying the sutilains immediately followed by a dry sterile dressing Rationale: The wound should be cleansed with a sterile solution before treatment. The nurse then should thoroughly moisten the wound with sterile normal saline or sterile water and apply a loose thin dressing after applying a thin film of sutilains extending ¼ to ½ inch beyond the area to be debrided. The ointment should be refrigerated.

The nurse is assigned to assist in caring for a client with frostbite of the toes. Which would the nurse anticipate to be prescribed for this condition?

Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs Rationale: Frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm-water bath for 15 to 20 minutes or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite.

An African American client has been admitted for a skin rash on his lower back. Which techniques would the nurse best rely on when assessing the skin rash? Select all that apply.

- palpation - induration Rationale: The darker a person's skin, the more difficult it is to assess for changes in color. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation for warmth and induration rather than observation. Visualization is often not helpful because of skin color; percussion and auscultation are not the appropriate assessment skills for skin rash.

Sodium hypochlorite is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?

Ensure that the solution is freshly prepared before use.

The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse would include on the poster instructions to avoid which activities?

Being in the sun for prolonged periods during the daytime hours to ensure absorption of vitamin D Rationale: The client should be instructed to avoid sun exposure during the daytime hours when the sun is strongest. Sunscreen, a hat, opaque clothing, and sunglasses should be worn when spending time outdoors. The client should examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

The nurse prepares to assist a primary health care provider with examining the client's skin with a Wood's light. Which action would be included in the plan for this procedure?

Darken the room for the examination.

A client is undergoing radiation therapy to treat lung cancer. Which instructions would the nurse reinforce to the client with regard to skin care? Select all that apply.

Do not remove any of the markings for radiation treatment. Use the hand to wash the affected area rather than a washcloth. Shower or wash the area once a day using warm water and mild soap.

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which sign/symptom during the first 24 hours after the burn injury?

Elevated hematocrit levels

The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position would the nurse anticipate being prescribed for the client?

Elevating and immobilizing the affected leg Rationale: Autografts placed over joints or on the lower extremities are often elevated and immobilized after surgery for 3 to 7 days. This period of immobilization allows time for the autograft to adhere and attach to the wound bed.

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart Rationale: Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation. Options 1, 2, and 3 are incorrect.

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Positive culture results

A client diagnosed with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse would perform which priority action while using this solution?

Rinse off the solution immediately following irrigation.

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?

"Do you have any allergies?"

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 pm."

A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client?

"Take a shower immediately, and lather and rinse several times." Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the skin. The client should be instructed to shower immediately, to lather the skin several times, and to rinse each time in running water. Calamine lotion is a treatment that is used when dermatitis develops. It is not necessary for the client to be seen in the emergency department at this time.

The nurse in the emergency department is caring for a client who sustained a large laceration to the lips and cheek from a dog bite. Which actions would the nurse take? Select all that apply.

- Administer analgesics as prescribed - Anticipate a plastic surgery consultation - Report the dog bite to the police department - Administer prophylactic antibiotics as prescribed

A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which would the nurse include in the plan of care? Select all that apply.

- Administering pain medications as prescribed - Monitoring the donor site and the graft site for signs of infection

Using the rule of nines, calculate the burn percentage for the client. Which matches your calculations? Refer to the figure; the burned area is the darkly shaded area. Refer to figure.

19% Rationale: The rule of nines is a quick method for early assessment of burn surface area. The head and neck are equal to 9%; each arm is equal to 9%; each leg is equal to 18%; the entire trunk is equal to 36%; and the genitalia are equal to 1%.

Which individual is least likely to be at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The nurse determines that which individual presenting to the clinic is at the greatest risk for development of an integumentary disorder?

An outdoor construction worker rationale: Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. An older client may be at a higher risk than a younger individual because immobility and lack of nutrition may increase the older person's risk. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. The physical education teacher is at low or no risk of developing an integumentary problem

A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?

Appearance Rationale:The client with a burn injury experiences structural and functional changes of the integumentary system as a result of this injury. The client's statement indicates a problem with appearance. Options 1, 3, and 4 do not relate to the client's statement.

A client comes to a primary health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?

Bull's-eye rash Rationale: The classic characteristic of Lyme disease is a small bite with a bull's-eye rash, although not all individuals who sustain a bite develop this rash. A painful rash around a necrotic lesion is indicative of a brown recluse spider bite. Papules, vesicles, and oval lesions are not characteristics of Lyme disease.

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable. Rationale: There is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite.

The nurse prepares to assist in instructing a client about Lyme disease. Which would the nurse include in the instructions?

It is caused by a tick carried by deer.

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse would make which response to the client?

The local anesthetic may cause a burning or stinging sensation." Rationale: Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. Options 1, 3, and 4 are incorrect.

Which would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses

The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury?

The ulcer is superficial and characterizes an abrasion.

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication?

There may be an infection at the central catheter site, which can lead to septicemia. Rationale: Redness, warmth, and purulent drainage are signs of an infection, not an allergic reaction. Infiltration causes the surrounding tissue to become cool and pale.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus Rationale: Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

Which clients are at risk for developing skin breakdown? Select all that apply.

- a client who is underweight - a client diagnosed with HF - a client diagnosed with spinal cord injury

The nurse is reinforcing instructions to a client on how to care for a punch biopsy site after the procedure is done. Which would the nurse include in the instructions? Select all that apply.

- Change the bandage daily until site is healed. - Apply topical antibiotic ointment as prescribed.

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply.

- Clean with mild soap and water - Encourage adequate nutritional intake. - Apply a dressing that allows oxygen to pass through.

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5% Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the upper half of the posterior trunk equals 9%, and the back of both arms equals 9%, totaling 22.5%.

The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which?

Autograft Rationale: It is most desirable to graft the client's own skin (autograft), but when this is not possible, a homograft (the skin of another person [allograft], obtained from a cadaver), a heterograft (xenograft, usually obtained from a pig), or artificial (biosynthetic) skin, such as Biobrane, can be used as a temporary measure.

The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?

"If the patch comes off, I need to reapply it."

A client is being admitted to the hospital for the treatment of acute cellulitis of the lower left leg. The client asks the nurse to explain what cellulitis means. Which response would the nurse give to the client's question?

"It is a skin infection that involves the deeper skin layers and subcutaneous fat."

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply.

It is highly metastatic Lesion is a nevus that has changed in color.

The client is receiving a full-thickness graft to a burn on the hand. The nurse understands that a full-thickness graft is being applied instead of a split-thickness graft because of which reason?

It provides better cosmetic results.

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse would expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply.

Lesion has a waxy border An irregularly shaped lesion

The nurse is reinforcing sun exposure precautions to a group of older clients. Which would the nurse include in the instructions? Select all that apply.

-Apply sunscreen liberally 15 to 30 minutes before sun exposure. - Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. - It is best to avoid exposure to the sun during the day between 10:00 a.m. and 4:00 p.m.

A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure?

"I need to stop taking my antihistamine 2 days before I come to the clinic for the test."

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area." Rationale: Newly healed skin is more sensitive to the cold, and the client should be instructed to wear warm clothing. The client should wash with a mild soap, rinse thoroughly, and pat the skin dry with a clean towel. Newly healed skin sunburns easily, and direct sunlight needs to be avoided. Products that contain perfume, alcohol, or lanolin should be avoided because they tend to irritate newly healed skin.

A client sustains a burn injury to the entire right and left arms, including the hands. Which emergency interventions would the nurse take before transferring the client to the burn center? Select all that apply.

- Apply cool water to the area - Wrap burned fingers separately to prevent sticking together. - Cover the burns with a clean dry cloth as directed by a burn center

The nurse is caring for a client on transmission-based precautions who has herpes zoster, or shingles. Which are some of the most important skin issues associated with this condition? Select all that apply.

- Lesions are very contagious when they are fluid-filled blisters. - Eruptions can last several weeks, and the severe pain (postherpetic neuralgia) often persists after the lesions have resolved - To reduce the risk of transmitting the virus to others, clients with lesions are separated from other clients until lesions have crusted.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

- Lightly scrub the stoma with soap and water. - Cut the opening on the appliance ½ inch larger than stoma.

The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?

Administer an opioid analgesic last taken 6 hours ago.

After 7 days of wound care, a client who has a well-granulated pressure injury reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?

Ambulation three times daily

A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would expect which assessment finding?

Appearance of reddish-blue lesions on the lower extremities

The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse would question which prescription?

Apply cold compresses to the affected area

The nurse is caring for a client with a diagnosis of pemphigus. The nurse would include which interventions in the plan of care for the client? Select all that apply

Applying prescribed topical antibiotic Administering prescribed corticosteroid Applying Domeboro solution to the affected skin

The primary health care provider has prescribed a bacteriostatic agent effective against both gram-positive and gram-negative organisms for application to a burn wound. The nurse determines that which medication has been prescribed?

Mafenide acetate Rationale: Mafenide acetate is a bacteriostatic agent effective against both gram-positive and gram-negative organisms. Silver nitrate has antimicrobial action. Silver sulfadiazine interferes with DNA synthesis by binding to bacterial cell membrane. Polymyxin B-bacitracin has wide-spectrum antibiotic action.

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8°F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection.

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The stinger is still visible in her arm. What would be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger.

The nurse reinforces instructions to a client who has complained of chronic dry skin and episodes of pruritus. Which client statement indicates the need for further teaching?

"I should use a dehumidifier, especially during the winter months."

Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?

"I will apply the ointment once a day and cover it with a sterile dressing" rationale: Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing.

The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton. Which statement by the client indicates an understanding regarding the application of this medication?

"I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

The nurse is reinforcing discharge instructions to a client who had a skin biopsy. Which statement by the client indicates the need for further teaching?

"I will remove the dressing when I get home and wash the site with tap water."

The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?

"My clothes can be laundered with other household members' clothes." Rationale: It is necessary to separate the client's laundry from other household members' clothing. Thorough handwashing, separating laundry, and separate washing of the client's dishes are required because the infection is contagious as long as skin lesions are present. Antibiotics are administered and should be continued as prescribed.

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply.

- knees -elbows -base of spine Rationale: The plaques most often appear on the skin of the elbows, knees, and base of the spine of a client with psoriasis. The plaques do not often appear on the face or the abdomen.

The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which would the nurse include in the instructions? Select all that apply.

-Use moisturizers and sunscreens. -Wash new clothing before it is worn. -Use mild detergent and rinse clothes twice. -Maintain room temperature at 68°F to 75°F. -Wear open-weave fabrics and loose clothing.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%.

The nurse is checking her clients for skin breakdown. Which client would have the lowest priority for concern in the development of skin breakdown?

A client with a lowered mental awareness status Rationale: Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and a lowered mental awareness can contribute to the development of skin breakdown. However, the least likely risk as presented in the options is the lowered mental awareness status.

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome?

Characteristic of a thrush infection Rationale: Candidiasis is a fungal infection caused by Candida albicans. When it occurs in the mouth, it is called thrush and appears as white plaques. Although it can occur in an immunocompromised client, it is not considered to be common

An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. Which combination of dietary items would the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, milk Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Options 1, 2, and 3 do not provide protein or vitamin C

A client with jaundice is complaining of pruritus. Which strategy would the nurse institute to help control the problem and prevent injury?

Pat the skin dry after bathing.

A client had a radical neck dissection with a musculocutaneous flap. Twenty-four hours following the procedure, the nurse observes that the flap has a slightly blue hue. The nurse draws which conclusion?

Venous circulation is being impaired Rationale:The blue color is a sign of venous engorgement resulting from venous stasis, which increases local tissue hypoxia and can lead to necrosis of the area affected. This is not a normal expectation. Heat application would cause more damage to the tissue. There is no evidence to support option 4.

The nurse prepares to care for a client with acute cellulitis of the lower leg. Which treatment would the nurse anticipate being prescribed for the client?

Warm compresses to the affected area Rationale: Warm compresses may be used to decrease discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics are initiated. Heat lamps can cause more disruption to tissue that is already inflamed. Continuous cold and hot compresses are not the best measures.

The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which?

Weeping of the skin Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but are not described as moist desquamation.

A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding would the nurse note in this condition?

White skin that is insensitive to touch Rationale: Findings in frostbite include white or blue skin that is hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, blisters or blebs, or tissue edema appears. Gangrene develops in 9 to 15 days.

The nurse is reviewing a focused assessment done on a client's integumentary system. Which physical examination assessments are related to inspection? Select all that apply.

- Nails for shape, contour, color, thickness and cleanliness - Skin for color, integrity, scars, lesions, and signs of breakdown - Facial and body hair for distribution, color, quantity and hygiene - Skin temperature, texture, moisture, thickness, turgor, and mobility

A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the primary health care provider to prescribe which measure to maximize the effectiveness of this therapy?

Covering the application with a warm, moist dressing and an occlusive outer wrap

The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client?

Crusting rationale: The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a potential complication.

The primary health care provider suspects a client has herpes zoster. To confirm the diagnosis of herpes zoster, for which diagnostic test does the nurse gather equipment?

Culture of the lesion Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the cause of chickenpox. A viral culture of the lesion provides the definitive diagnosis. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. A biopsy will determine tissue type. During a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The client, diagnosed with Lyme disease stage 2, asks the nurse "what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2?

Neurologic defects Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage 3. A rash appears in stage 1.

The nurse is working on a surgical unit. Which surgical clients are most at risk for wound infection? Select all that apply.

- Wound from repair of a perforated appendix - Gunshot wound that punctured the small intestine - Traumatic wound to the abdomen and intentionally left open for several days - Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect

The nurse reviews a client's chart and notes that the primary health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which would the nurse expect to note during data collection?

Red, shiny skin around the nail bed Rationale: Paronychia or infection around the nail is characterized by red, shiny skin, often associated with painful swelling. These infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. Often these become secondarily infected with bacteria or fungus, which later involves the nail.

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding would the nurse note if this disorder is present?

Silvery-white scaly lesions

The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse would document the pressure injury as which category?

Stage 2 Rationale: A stage II pressure injury is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, shallow crater, or a blister. A stage I pressure injury is a reddened area that doesn't blanch but has intact skin. Stages III and IV pressure injuries are full thickness, or full thickness with necrosis or damage to muscle, bone, or supportive tissue, respectively.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions would the nurse provide? Select all that apply.

Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious.

A client has a noninfected pressure injury on the left heel. The nurse would use which sterile solution to cleanse the wound as part of a dressing change procedure?

Normal saline Rationale: Normal saline (0.9%) should be used for cleansing pressure injuries, unless there is a specific prescription for another solution. Normal saline is isotonic (unlike water) and does not damage cells that are needed for healing (as povidone-iodine and hydrogen peroxide do).

The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area would provide the best information?

Palms of the hands Rationale: In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms and soles at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What would the nurse expect to find when checking the client's sacral area?

Partial-thickness skin loss of the epidermis Rationale: With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial, and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3, and tunneling develops during stage 4.

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage?

36% rationale: According to the rule of nines, the entire right leg equals 18%, and the anterior thorax equals 18%. This totals 36%.

The nurse is caring for a postoperative client. The nurse knows that the primary processes of normal wound healing include which phases? Select all that apply.

- Inflammatory or (lag) phase - Maturation or (remodeling) phase - Proliferative or (connective tissue repair) phase

The nurse in a primary health care provider's office has scheduled a client with a possible allergen-causing dermatitis to be seen in 1 week for a patch test. The nurse explains the procedure for the patch test and includes which in the explanation? Select all that apply.

- The allergen will be placed on the skin and covered with an airtight dressing. - A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the primary health care provider's prescription sheet expecting which to be prescribed? Select all that apply.

- wound culture - ABX therapy - warm compresses

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?

Can stain the skin and hair Rationale: Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It frequently can stain the skin and hair, and clients should be taught about this aspect of the medication. It has an unpleasant odor and can cause phototoxicity. It does not carry a risk for systemic effects.

A client asks the nurse about the causes of acne. The nurse would respond by making which statement to the client?

"The exact cause of acne is not known." Rationale: The exact cause of acne is unknown. Exacerbations that coincide with the menstrual cycle result from hormonal activity. Oily skin alone is not the cause of acne. Heat, humidity, and excessive perspiration also play a role in exacerbation of acne. There is no evidence that consumption of foods such as chocolate, nuts, or fatty foods affects acne.

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim would be transported to the hospital first?

A victim with singed nasal and facial hair and difficulty breathing

A client arrives at the emergency department and has experienced frostbite to the right hand. What would the nurse expect to find when inspecting the client's hand?

A white color of the skin that is insensitive to touch Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

Chicken breast, broccoli, strawberries, and milk Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin and jelly have no nutrient value. Spaghetti is a complex carbohydrate.