Ch 15 Integumentary Problems

2. Use compression wraps consistently. 3. Administer analgesics before wound care. 5. Encourage right ankle flexion exercises. 6. Clean wound with a nonirritating solution.

1. Which actions will the nurse use when treating a client with a venous ulcer on the right lower leg? Select all that apply. 1. Position the right leg lower than the heart. 2. Use compression wraps consistently. 3. Administer analgesics before wound care. 4. Maintain a dry wound environment. 5. Encourage right ankle flexion exercises. 6. Clean wound with a nonirritating solution.

4. An irregular border is seen on a black mole on the scalp.

10. After the nurse performs a skin assessment on a 70-year-old new resident in a long-term care facility, which finding is of most concern? 1. Numerous striae are noted across the abdomen and buttocks. 2. All the toenails are thickened and yellow. 3. Silver scaling is present on the elbows and knees. 4. An irregular border is seen on a black mole on the scalp.

1. Bluish color around the lips and earlobes

11. Which assessment finding calls for the most immediate action by the nurse? 1. Bluish color around the lips and earlobes 2. Yellow color of the skin and sclera 3. Bilateral erythema of the face and neck 4. Dark brown spotting on the chest and back

4. The client's spouse is currently receiving cancer chemotherapy.

12. The nurse obtains this information about a 60-year-old client who has a shingles infection. Which finding is of most concern? 1. The client has had symptoms for about 2 days. 2. The client has severe burning-type discomfort. 3. The client has not had the herpes zoster vaccination. 4. The client's spouse is currently receiving cancer chemotherapy.

4. Auscultate the client's breath sounds.

13. Which of these actions will the nurse take first for a client who has arrived in the emergency department with sudden-onset urticaria and intense itching? 1. Ask the client about any new medications. 2. Administer the prescribed cetirizine. 3. Apply topical corticosteroid cream. 4. Auscultate the client's breath sounds.

1. "My husband and I are thinking of starting a family soon."

14. A 22-year-old woman who has been taking isotretinoin to treat severe cystic acne makes all these statements while being seen for a follow-up examination Which statement is of most concern? 1. "My husband and I are thinking of starting a family soon." 2. "I don't think there has been much improvement in my skin." 3. "Sometimes I get nauseated after taking the medication." 4. "I have been experiencing a lot of muscle aches and pains."

3. Scheduling a follow-up appointment for the client in 2 days

15. A client is scheduled for patch testing to determine allergies to several substances. Which action associated with this test should the nurse delegate to unlicensed assistive personnel (UAP) working in the allergy clinic? 1. Explaining the purpose of the testing to the client 2. Examining the patch area for evidence of a reaction 3. Scheduling a follow-up appointment for the client in 2 days 4. Monitoring the client for anaphylactic reactions to the testing

1. A 32-year-old client with pneumonia who has a new prescription for doxycycline

16. The nurse is planning hospital discharge teaching for four clients. For which client is it most important to instruct about the need to use sunscreen? 1. A 32-year-old client with pneumonia who has a new prescription for doxycycline 2. A fair-skinned 55-year-old client with psoriasis who works outside for 8 hours daily 3. A dark-skinned 62-year-old client who has had keloids injected with hydrocortisone 4. A 78-year-old client with a red, pruritic rash caused by an allergic reaction to penicillin

3. Reminding the family to help the client to the commode every 2 hours during the day

17. The home health nurse is caring for a 72-year-old client who has a stage II pressure ulcer, with risk factors of poor nutrition, bladder incontinence, and immobility. Which nursing action should be delegated to the unlicensed assistive personnel (UAP)? 1. Telling the client and family to apply the skin barrier cream in a smooth, even layer 2. Completing a diet assessment and suggesting changes in diet to improve the client's nutrition 3. Reminding the family to help the client to the commode every 2 hours during the day 4. Evaluating the client for improvement in documented areas of skin breakdown or damage

1. Applying nystatin powder to the area three times daily

18. The charge nurse in a long-term care facility that employs RNs, LPNS/LVNS, and unlicensed assistive personnel (UAP) as staff members is planning the care for an 80-year-old client who has candidiasis in the skinfolds of the abdomen and groin. Which intervention is best to assign to an LPN/LVN? 1. Applying nystatin powder to the area three times daily 2. Cleaning the skinfolds every 8 hours and drying thoroughly 3. Evaluating the need for further antifungal treatment at least weekly 4. Assessing for ongoing risk factors for skin breakdown and infection

2. Administer prescribed analgesics before meals.

19. After reviewing the medical record for a client who has an oral herpes simplex infection after being treated with chemotherapy, which intervention has the highest priority? 1. Offer reassurance that herpes can be treated with antiviral medication. 2. Administer prescribed analgesics before meals. 3. Offer the client frequent small meals and snacks. 4. Encourage the client to maintain contact with some family members.

2. Tenting of the skin on the forearms

2. After the nurse has performed a skin assessment on a recently admitted 19-year-old client, which finding is the highest priority to report to the health care provider? 1. Mole 2 mm in diameter on the chest 2. Tenting of the skin on the forearms 3. Patches of vitiligo around both eyes 4. Scattered brown macules on the face

4. "Are you taking any new medications?"

20. A client admitted to the emergency department reports new-onset itching of the trunk and groin. The nurse notes multiple reddened wheals on the chest, back, and groin. Which question should the nurse ask next? 1. "Do you have a family history of eczema?" 2. "Have you been using sunscreen regularly?" 3. "How do you usually manage stress?" 4. "Are you taking any new medications?"

2. Rinse the back and legs with 4 L of sterile normal saline.

21. A client who has extensive blister injuries to the back and both legs caused by exposure to toxic chemicals at work is transferred to the emergency department. Which prescribed intervention will the nurse implement first? 1. Infuse lactated Ringer's solution at 250 mL/hr. 2. Rinse the back and legs with 4 L of sterile normal saline. 3. Obtain blood for a complete blood count and electrolyte levels. 4. Document the percentage of total body surface area burned.

3. A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg

22. The nurse has just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention? 1. A 22-year-old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left 2. A 34-year-old client who returned from skin-graft surgery 3 hours ago and is reporting level 8 pain (on a scale of 0 to 10) 3. A 45-year-old client with partial-thickness leg burns who has a temperature of 102.6°F (39.2°C) and a blood pressure of 98/46 mm Hg 4. A 57-year-old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L (5.1 mmol/L)

150ml/hr

23. A client with cellulitis is to receive linezolid 600 mg IV over 2 hours. Based on the medication label, the nurse will set the infusion pump for ____________ mL/hr.

4. Clean off the crust from the lesion. 1. Obtain specimen for culture. 2. Apply topical antibiotic ointment. 5. Apply a sterile dressing to the wound. 3. Give the client a hand hygiene handout.

24. In which order will the nurse take these actions which are needed for a client seen in the family medicine clinic and diagnosed with impetigo? 1. Obtain specimen for culture. 2. Apply topical antibiotic ointment. 3. Give the client a hand hygiene handout. 4. Clean off the crust from the lesion. 5. Apply a sterile dressing to the wound.

1. Gown 2. Gloves

25. Which personal protective equipment will the nurse need when planning a dressing change for a client with a methicillin-resistant Staphylococcus aureus-infected skin wound? Select all that apply. 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. Booties

4. The client takes 325 mg of aspirin daily.

26. The nurse takes the health history of a client who has been admitted to the same-day surgery unit for elective facial dermabrasion. Which information is most important to convey to the plastic surgeon? 1. The client does not routinely use sunscreen. 2. The client has a family history of melanoma. 3. The client has not eaten anything for 8 hours. 4. The client takes 325 mg of aspirin daily.

3. A 67-year-old client who requires a dressing change after hydrotherapy for a pressure ulcer

27. The charge nurse on a medical-surgical unit is working with a newly graduated RN who has been on orientation to the unit for 3 weeks. Which client is best to assign to the new graduate? 1. A 34-year-old client who was just admitted to the unit with periorbital cellulitis 2. A 40-year-old client who needs discharge instructions after having skin grafts to the thigh 3. A 67-year-old client who requires a dressing change after hydrotherapy for a pressure ulcer 4. A 78-year-old client who needs teaching before a punch biopsy of a facial lesion

3. The client reports frequent epigastric pain.

28. When the nurse is evaluating a client who has been taking prednisone 30 mg/day to treat contact dermatitis, which finding is most important to report to the health care provider? 1. The glucose level is 136 mg/dL (7.6 mmol/L). 2. The client states, "I am eating all the time." 3. The client reports frequent epigastric pain. 4. The blood pressure is 148/84 mm Hg.

2. Giving doxycycline with a glass of milk to a client with cellulitis

29. The charge nurse is supervising a newly hired RN. Which action by the new RN requires the most immediate action by the charge nurse? 1. Obtaining an anaerobic culture specimen from a superficial burn wound 2. Giving doxycycline with a glass of milk to a client with cellulitis 3. Discussing the use of herpes zoster vaccine with a 25-year-old client 4. Teaching a newly admitted burn client about the use of pressure garments

3. The client is also taking simvastatin daily.

3. The home health nurse is caring for a client with a fun- gal infection of the toenails who has a new prescription for oral itraconazole. Which client information is most important to discuss with the health care provider (HCP) before administration of the itraconazole? 1. The client's toenails are thick and yellow. 2. The client is embarrassed by the infection. 3. The client is also taking simvastatin daily. 4. The client is allergic to iodine and shellfish.

1. Temperature 100.9°F (38.3°C)

30. Which finding by the clinic nurse about a client who has been taking adalimumab to treat psoriasis is most indicative of a need for a change in therapy? 1. Temperature 100.9°F (38.3°C) 2. Patches of scaly skin on chest 3. Erythema on sun-exposed areas of skin 4. Client report of worsening depression

2. "Let's look at the client assignments for today and make changes so that you can give the needed care and maintain good infection control."

31. At the beginning of the shift, an unlicensed assistive personnel (UAP) tells the nurse, "I have several clients today who have wound infections. I will do my best, but if I put on a gown and gloves every time I go into their rooms, I will never get all the care done!" Which response by the nurse is best? 1. "I know you are busy, but please try to comply with the standard infection control measures because these clients have serious infections." 2. "Let's look at the client assignments for today and make changes so that you can give the needed care and maintain good infection control." 3. "If you are unable to follow infection control standards, perhaps you need a review class in correct use of personal protective equipment." 4. "Tell me what you think are the most important times to use personal protective equipment to prevent infections from spreading."

1. The client has a newborn infant.

4. The health care provider (HCP) prescribes permethrin application for all family members of a client who has scabies. Which client information will be most important for the nurse to discuss with the HCP before client teaching about the medication? 1. The client has a newborn infant. 2. Burrows are noted on the wrists. 3. The client and family are homeless. 4. Family members are asymptomatic.

3. Monitoring the surgical site for swelling, bleeding, or pain

5. The nurse is caring for a client who has just had a squamous cell carcinoma removed from the face. Which action can be assigned to an experienced LPN/LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for 1 week after surgery

4. Cleaning and changing the dressing on the ulcer every morning

6. The charge nurse in a long-term care (LTC) facility that employs RNs, LPNS/LVNS, and unlicensed assistive personnel (UAP) is planning care for a resident with a stage III sacral pressure ulcer. Which nursing intervention is best to assign to an LPN/LVN? 1. Choosing the type of dressing to be used on the ulcer 2. Using the Braden scale to assess for pressure ulcer risk factors 3. Assisting the client in changing position at frequent intervals 4. Cleaning and changing the dressing on the ulcer every morning

2. Client who has just arrived from the emergency department with facial burns sustained in a house fire

7. The nurse has just received a change-of-shift report for the burn unit. Which client should be assessed first? 1. Client with deep partial-thickness burns on both legs who reports severe and continuous leg pain 2. Client who has just arrived from the emergency department with facial burns sustained in a house fire 3. Client who has just been transferred from the post- anesthesia care unit after having skin grafts applied to the anterior chest 4. Client admitted 3 weeks ago with full-thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

3. Administer morphine sulfate 10 mg IV. 4. Débride the wound of eschar using gauze sponges. 2. Obtain specimens for aerobic and anaerobic wound cultures. 1. Apply silver sulfadiazine ointment. 5. Cover the wound with a sterile gauze dressing.

8. The nurse is performing a sterile dressing change for a client with infected deep partial-thickness burns of the chest and abdomen. List the steps in the order in which each should be accomplished. 1. Apply silver sulfadiazine ointment. 2. Obtain specimens for aerobic and anaerobic wound cultures. 3. Administer morphine sulfate 10 mg IV. 4. Débride the wound of eschar using gauze sponges. 5. Cover the wound with a sterile gauze dressing.

3. A 45-year-old client with infected partial-thickness back and chest burns who has a dressing change scheduled

9. Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? 1. A 23-year-old client who has just been admitted with burns over 30% of the body after a warehouse fire 2. A 36-year-old client who requires discharge teaching about nutrition and wound care after having skin grafts 3. A 45-year-old client with infected partial-thickness back and chest burns who has a dressing change scheduled 4. A 57-year-old client with full-thickness burns on both arms who needs assistance in positioning hand splints