Ch. 22-24: Integumentary
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?
27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and the anterior (4.5%) and posterior (4.5%) left arm equals 9%.
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?
600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours & then the remaining half is given over 16 hours: 4 ́ 80 ́ 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
Which activities can the nurse working in the outpatient clinic delegate to a LPN/VN? (Select all that apply.) a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems & allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion.
A, C Skills such as administration of patch testing and sterile dressing technique are included in LPN/VN education & scope of practice. Obtaining a health history & patient education require registered nurse (RN) level education & scope of practice.
A nurse is teaching a patient with contact dermatitis of the arms & legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan? (Select all that apply.) a. Add oil to your bath water to moisturize the affected skin. b. Cool, wet clothes or compresses can be used to reduce itching. c. Use an over-the-counter (OTC) antihistamine to reduce itching. d. Take cool or tepid baths several times daily to decrease itching. e. Rub yourself dry with a towel after bathing to prevent skin maceration.
B, C, D Cool or tepid baths, cool dressings, & OTC antihistamines all help reduce pruritus & scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry.
The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations? (Select all that apply.) a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis
D, E A patient who has worked as a landscaper is at risk for skin lesions caused by sun exposure such as erythema and actinic keratosis. Vitiligo, alopecia,& intertrigo are not associated with excessive sun exposure.
In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Give IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.
D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to give pain medications. The wound will then be cleaned, antibacterial cream applied, & covered with a new sterile dressing. The last action should be to document the appearance of the wound.
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin b. Alopecia of the affected area c. Dryness and scaling in the area d. Reddish-brown skin discoloration
a. Thinning of the affected skin Thinning of the skin indicates atrophy, a possible adverse effect of topical corticosteroids. The HCP should be notified so that the medication can be changed or tapered. Alopecia, red-brown discoloration, & dryness and scaling of the skin are not adverse effects of topical corticosteroid use.
The nurse notes white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"
a. "Are you taking any medications?" The appearance of the lesions is consistent with an oral candidiasis (thrush) infection, which can occur in patients who are taking medications such as immunosuppressants or antibiotics. Candidiasis is not associated with poor oral hygiene or lower respiratory infections. The lesions do not look like an oral herpes infection
A patient arrives in the ED with facial & chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate for breath sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer'ssolution.
a. Auscultate for breath sounds. A patient with facial & chest burns is at risk for inhalation injury & assessment of airway & breathing is the priority. The other actions will be completed after airway management is assured.
Which instructions should the nurse include in the teaching plan for a patient with impetigo? a. Clean the crusted areas with soap and water. b. Spread alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas..
a. Clean the crusted areas with soap and water. The treatment for impetigo includes softening of the crusts with warm saline soaks & then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a skin biopsy. b. Teach the use of corticosteroid cream. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.
a. Prepare the patient for a skin biopsy. Because the appearance of the lesion is suggestive of actinic keratosis or possible squamous cell carcinoma, the appropriate treatment would be excision and biopsy. OTC corticosteroids, topical antibiotics, & Retin-A would not be used for this lesion.
An employee spills industrial acid on both arms & legs at work. What action should the occupational health nurse take? a. Remove nonadherent clothing & wristwatch. b. Apply an alkaline solution to the affected area. c. Place a cool compress on the area of exposure. d. Cover the affected area with dry, sterile dressings.
a. Remove nonadherent clothing & wristwatch. With chemical burns, the first action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if the face was exposed). Flush the chemical from the wound & surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution can cause more injury.
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the HCP when a nondiabetic patient's serum glucose is elevated.
a. The new nurse uses clean gloves when applying antibacterial cream to a burn wound. Sterile gloves should be worn when applying meds or dressings to a burn. Hypothermia is an indicator of possible sepsis, & cultures are appropriate. Nondiabetic patients may need insulin because stress & high-calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration & should be used just before &during dressing changes for pain management.
The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.
a. The patient recently had an intrauterine device removed. Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other BC methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use.
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a UTI? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.
a. Use a sunscreen with a high SPF when exposed to the sun. The patient should stay out of the sun. If that is not possible, teach the patient to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate.
A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the Elidel." d. "I will rub the medication in gently every morning and night."
b. "If the medication burns when I apply it, I will wipe it off." The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus & that the medication should be left in place. The other statements by the patient are accurate & indicate that patient teaching has been effective.
A young adult patient who is in the rehabilitation phase 6 months after a severe face & neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response should the nurse make? a. "Most people recover after a burn & feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "Why do you feel that way? It will get better as your recovery progresses." d. "It is really too early to know how much your life will be changed by the burn."
b. "It's true that your life may be different. What concerns you the most?" This response acknowledges the patient's feelings & asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate but do not acknowledge the anxiety & depression that the patient is expressing.
The health care provider prescribes topical 5-FUfor a patient with actinic keratosis on the left cheek. Which statement should the nurse include in the patient's instructions? a. "5-FU will shrink the lesion to prepare for surgical excision." b. "Your cheek area will be eroded and take several weeks to heal." c. "You may develop nausea and anorexia, but good nutrition is important during treatment." d. "You will need to avoid crowds because of the risk for infection caused by chemotherapy."
b. "Your cheek area will be eroded and take several weeks to heal." Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea.
Which patient should the nurse assess first? a. A patient with burns who reports a level 8 (0-10 scale) pain. b. A patient with smoke inhalation who has wheezes & altered mental status. c. A patient with full-thickness leg burns who is scheduled for a dressing change. d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr.
b. A patient with smoke inhalation who has wheezes & altered mental status. This patient has evidence of lower airway injury & hypoxemia & should be assessed at once to determine the need for O2 or intubation (or both). The other patients should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.
When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? a. Suggest an appointment with a dermatologist. b. Assess the patient for evidence of liver disease. c. Teach the patient about skin changes with aging. d. Discuss the use of sunscreen to prevent skin cancers.
b. Assess the patient for evidence of liver disease. Angiomas are a common occurrence as patients get older, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to teach the patient about the effects of aging on the skin & about the effects of sun exposure, but the first action should be further assessment.
A patient admitted with burns over 30% of the body surface 2 days ago now has dramatically increased urine output. Which action should the nurse plan to support maintaining kidney function? a. Monitoring white blood cells (WBCs). b. Continuing to measure the urine output. c. Assessing that blisters and edema have subsided. d. Encouraging the patient to eat adequate calories.
b. Continuing to measure the urine output. The patient's urine output indicates that the patient is entering the acute phase of the burn injury & moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes, & the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hrs, it may be longer in some patients. Blisters & edema begin to resolve, but this process requires more time. WBCs may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. Although adequate nutrition is important for healing, it does not ensure adequate kidney functioning.
A nurse is caring for a patient who has burns of the ears, head, neck, & right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows & extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.
b. Elevate the right arm and hand on pillows & extend the fingers. The right hand & arm should be elevated to reduce swelling & the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, & the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be kept in an extended position to avoid contractures.
When assessing a patient who spilled hot oil on the right leg & foot, the nurse notes dry, pale, & hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction
b. Full-thickness skin destruction With full-thickness skin destruction, the appearance is pale & dry or leathery, and the area is painless because of the associated nerve destruction. Erythema, swelling, & blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, & pain.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral nutrition. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day.
b. Insert a feeding tube and initiate enteral nutrition. Enteral nutrition can usually be started during the emergent phase at low rates and increased over 24-48 hrs to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs & may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins & minerals may be given during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve GI function, & is not routinely used in burn patients unless the GI tract is not available for use.
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient uses a tanning booth weekly. c. The patient is fair-skinned with blue eyes. d. The patient's mother died of malignant melanoma.
b. The patient uses a tanning booth weekly. Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma.
A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of contraception used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face
b. Method of contraception used by the patient Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable contraception has the most potential for serious adverse medication effects.
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased, & no wheezes are audible. What action should the nurse take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the HCP & prepare for endotracheal intubation. c. Document the results & continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position & reassess breath sounds.
b. Notify the HCP & prepare for endotracheal intubation. The patient's history& clinical manifestations suggest airway edema, & the HCP should be notified ASAP so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.
b. Notify the health care provider. The decrease in pulse and numbness in a patient with circumferential burns shows decreased circulation to the legs & the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess pain level. b. Place on heart monitor. c. Check potassium level. d. Assess oral temperature.
b. Place on heart monitor. After an electrical burn, the patient is at risk for life-threatening dysrhythmias & should be placed on a heart monitor. Assessing the oral temperature & pain is not as important as assessing for dysrhythmias. Checking the K level is important, but it will take time before the lab results are back. The first intervention is to place the patient on a heart monitor & assess for dysrhythmias so that they can be monitored and treated if necessary.
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.
b. Press firmly on the lesion. If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg but will not be helpful in determining the etiology of the lesion.
Which integumentary assessment data from an older patient admitted with bacterial pneumonia should be of concern to the nurse? a. Brown macules on extremities b. Reports a history of allergic rashes c. Skin wrinkled with tenting on both hands d. Longitudinal nail ridges and sparse scalp hair
b. Reports a history of allergic rashes Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes & whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient.
During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. Confluent b. Symmetric c. Zosteriform d. Generalized
b. Symmetric The description of the lesions indicates that they are grouped in a bilateral distribution. The other terms are inconsistent with the description of the lesions.
A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding should the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles
b. Thickening of the skin around the ankles Lichenification is likely to occur in areas where the patient scratches the skin often. It results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur because of scratching the skin.
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the HCP? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.
b. Urine output of 41 mL over past 2 hours. The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the HCP because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic & HR should be less than 120 bpm. Serous exudate from the burns is expected during the emergent phase.
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face & neck burns has been having difficulty with body image over the past several months. Which statement by the patient best indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "Do you think dark beige makeup will cover this scar?" d. "I don't think my boyfriend will want to look at me now."
c. "Do you think dark beige makeup will cover this scar?" The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars shows a willingness to discuss appearance but not resolution of the problem. Because deep partial thickness burns leave permanent scars, a statement that the scars are temporary shows denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.
There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 42-yr-old with itching after using topical fluorouracil on the nose b. 50-yr-old with skin redness after having a chemical peel 3 days ago c. 38-year old with a 7-mm nevus on the face that has recently become darker d. 62-yr-old with multiple small, soft, pedunculated papules in both axillary areas
c. 38-year old with a 7-mm nevus on the face that has recently become darker The description of the lesion is consistent with possible malignant melanoma. The HCP should assess this patient ASAP. Itching is common after using topical fluorouracil, & redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife.
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be given in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 219 mL/hr b. 625 mL/hr c. 938 mL/hr d. 1875 mL/hr
c. 938 mL/hr Half of the fluid replacement using the Parkland formula is administered in the first 8 hours & the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.
Which patient is most appropriate for the burn unit charge nurse to assign to a RN who has floated from the hospital medical unit? a. A patient who has twice-daily burn debridements to partial thickness facial burns. b. A patient who just returned from having a cultured epithelial autograft to the chest. c. A patient who has a 15% weight loss from admission & will need enteral feedings. d. A patient who has blebs under an autograft on the thigh & has an order for bleb aspiration.
c. A patient who has a 15% weight loss from admission & will need enteral feedings. An RN from a medical unit would be familiar with malnutrition & with administration/ evaluation of response to enteral feedings. The other patients need burn assessment & care that is more appropriate for staff who regularly care for burned patients.
A patient with dark skin has been admitted to the hospital with acute decompensated heart failure. How would the nurse assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.
c. Check the lips and oral mucous membranes. Cyanosis persons with dark skin is more easily seen in the mucous membranes. Earlobe color may change in persons with light skin, but this change in skin color is hard to detect on darker skin. Application of pressure to the palms of the hands & nail bed assessment would check for adequate circulation but not for skin color.
When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; & thick, brittle nails. What is the nurse's most important action? a. Instruct the patient about the importance of nutrition for skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the HCP about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams & lotions to decrease dry skin.
c. Consult with the HCP about the need for further diagnostic testing. The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient's dry skin, & referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations.
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves b. Patch test instruments c. Cotton-tipped applicators d. Syringe and intradermal needle
c. Cotton-tipped applicators Fungal cultures are obtained by swabbing the affected area of the skin with cotton-tipped applicators. Sterile gloves are not needed because it is not a sterile procedure. Local injection or aspiration is not involved in the procedure. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens.
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light
c. Extremity movement All patients with electrical burns should be considered at risk for cervical spine injury, & assessment of extremity movement will provide baseline data. The other assessment data are necessary but not as essential as determining the cervical spine status.
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored & irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy b. Punch biopsy c. Incisional biopsy d. Excisional biopsy
c. Incisional biopsy An incisional biopsy would remove the entire mole & the tissue borders. The appearance of the mole indicates that it may be cancerous. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial lab results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours b. Continuing to monitor the laboratory results c. Increasing the rate of the ordered IV solution d. Typing and crossmatching for a blood transfusion
c. Increasing the rate of the ordered IV solution The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit & hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every hour).
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low-dose systemic chemotherapy is used to treat BCC.
c. Minimizing sun exposure reduces risk for future BCC. BCC is frequently associated with sun exposure, & preventive measures should be taken for future sun exposure. BCC spreads locally and does not metastasize to distant tissues. Because BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ringlike rashes with red, scaly borders over the entire scalp b. Red, hivelike papules and plaques with circumscribed borders c. Papular, wheal-like lesions with white deposits on the hair shaft d. Patchy areas of alopecia with small vesicles and excoriated areas
c. Papular, wheal-like lesions with white deposits on the hair shaft Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the base of the hair shaft. The other descriptions are more characteristic of other types of skin disorders.
Which abnormality on the skin of an older patient is the priority for the nurse to discuss with the health care provider? a. Dry, scaly patches on the face b. Numerous varicosities on both legs c. Petechiae on the chest and abdomen d. Small dilated blood vessels on the face
c. Petechiae on the chest and abdomen Petechiae are caused by pinpoint hemorrhages & are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient's HCP about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.
A patient who was found unconscious in a burning house is brought to the ED by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Place the patient on 100% O2 using a nonrebreather mask. d. Assess for singed nasal hair and dark oral mucous membranes.
c. Place the patient on 100% O2 using a nonrebreather mask. The patient's history & skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%. The other actions can be taken after the action to correct gas exchange.
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit of 53% b. Serum sodium of 147 mEq/L c. Serum potassium of 6.1 mEq/L d. Blood urea nitrogen of 37 mg/dL
c. Serum potassium of 6.1 mEq/L Hyperkalemia can lead to life-threatening dysrhythmias. The patient needs cardiac monitoring & immediate treatment to lower the K level. The other laboratory values are also abnormal & require changes in treatment, but they are not as immediately life threatening as the elevated K level.
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Inspect the contact burns. b. Check the blood pressure. c. Stabilize the cervical spine. d. Assess alertness and orientation.
c. Stabilize the cervical spine. Cervical spine injuries are often associated with electrical burns. Therefore, stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.
Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug? a. Bowel sounds b. Stool frequency c. Stool occult blood d. Abdominal distention
c. Stool occult blood H2 blockers & PPIs are given to prevent Curling's ulcer in the patient who has sustained burn injuries. PPIs usually do not affect bowel sounds, stool frequency, or appetite.
The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient's body. Which action should the nurse take first? a. Ensure the patient wears shoes with nonslip soles. b. Discourage using throw rugs throughout the house. c. Talk with the patient alone and ask about the bruising. d. Suggest that the health care provider prescribe radiographs.
c. Talk with the patient alone and ask about the bruising. The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse & should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs & shoes with slippery surfaces may contribute to falls. Radiographs may be needed if the patient has fallen recently & reports pain or decreased mobility. However, the nurse's first nursing action is to further assess the patient's safety.
The nurse teaches a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream.
c. The patient applies a thick layer of the cream to the affected skin. Creams and ointments should be applied in a thin layer to avoid wasting the medication. The other actions by the patient indicate that the teaching has been successful.
The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient reports incisional pain. b. The patient's heart rate is 100 beats/min. c. The skin around the incision is pale and cold. d. The patient is unable to sense touch on the eyelids.
c. The skin around the incision is pale and cold. Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be notified immediately. The other assessment data indicate a need for ongoing assessment or nursing action. AHR of 100 bpm may be related to the stress associated with surgery. Assessment of other vital signs & continued monitoring are appropriate. Because local anesthesia would be used for the procedure, numbness of the incisional area is expected immediately after surgery. The nurse should monitor for return of feeling.
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Water-resistant sunscreens provide good protection when swimming. c. Try to stay out of the direct sun between the hours of 10 AM-2 PM. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
c. Try to stay out of the direct sun between the hours of 10 AM-2 PM. The risk for skin damage from the sun is highest with exposure between 10 AM-2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.
Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.
c. Use warm water and a moisturizing soap when bathing. Warm water and moisturizing soap will avoid over drying the skin. Because older patients have dryer skin, daily bathing/shampooing are not necessary & may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel
c. Vanilla milkshake A patient with a burn injury needs high-protein & high-calorie food intake, & the milkshake is the highest in these nutrients. The other choices are not as nutrient dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice but low in protein. Bananas are a good source of potassium but are not high in protein and calories.
What is the most effective method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Apply antibiotic ointment over the wound. c. Wash hands and properly dispose of soiled dressings. d. Soak the dressing in sterile normal saline before removal.
c. Wash hands and properly dispose of soiled dressings. Careful hand washing & the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove & sterile saline use during wound care will not necessarily prevent spread of infection to others. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection.
Which nursing action prevents cross contamination when the patient's full-thickness burn wounds to the face are exposed? a. Using sterile gloves when removing dressings. b. Keeping the room temperature at 70° F (20° C). c. Wearing gown, cap, mask, and gloves during care. d. Giving IV antibiotics to prevent bacterial colonization.
c. Wearing gown, cap, mask, and gloves during care. Use of gowns, caps, masks, & gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings & washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.
d. Apply water-based cream to burned areas frequently. Application of water-based emollients will moisturize new skin &decrease flakiness & itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury.
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a BMI of 40 kg/m2 . What is the nurse's appropriate action? a. Discuss the use of drying agents to minimize infection risk. b. Instruct the patient about the use of mild soap to clean skinfolds. c. Teach the patient about treating fungal infections in the skinfolds. d. Ask the patient about a personal or family history of type 2 diabetes.
d. Ask the patient about a personal or family history of type 2 diabetes. The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it. The description of the patient's skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better.
A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of taking part in an online support group. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.
d. Ask the patient to describe the impact of psoriasis on quality of life. The nurse's initial actions should be to assess the impact of the disease on the patient's life & to allow the patient to verbalize feelings about
The nurse is caring for a patient diagnosed with furunculosis. Which action could the nurse delegate to the UAP? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient's personal hygiene d. Cleaning the skin with antimicrobial soap
d. Cleaning the skin with antimicrobial soap Cleaning the skin is within the education and scope of practice for UAP. Administering medication, obtaining cultures, and evaluation are higher level skills that require the education & scope of practice of licensed nursing personnel.
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Shield any unaffected areas with lead-lined drapes. b. Apply petroleum jelly to the areas around the lesions. c. Cleanse the skin carefully with antiseptic soap prior to PUVA. d. Have the patient use protective eyewear while receiving PUVA.
d. Have the patient use protective eyewear while receiving PUVA. The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, & petroleum jelly are not used to prevent skin damage.
During the emergent phase of burn care, which assessment is most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.
d. Measure hourly urine output. When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing & evaporative fluid loss. Mucous membrane assessment & skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage b. Cryosurgery c. Punch biopsy d. Surgical excision
d. Surgical excision The description of the mole is consistent with cancer, so excision & biopsy are indicated. Curettage & cryosurgery are not used if cancer is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter.
An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Schedule daily appointments for dressing changes. b. Describe the use of topical fluorouracil on the incision. c. Instruct how to use sterile technique to clean the suture line. d. Teach the use of cold packs to reduce bruising and swelling.
d. Teach the use of cold packs to reduce bruising and swelling. Application of cold packs to the incision after the surgery will help decrease bruising & swelling at the site. Because the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. After the Mohs procedure, the edges of the wound can be left open to heal, or the edges can be approximated & sutured together. The suture line can be cleaned with tap water. No daily dressing changes are indicated after the first dressing is removed.
The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient adds oilated oatmeal to the bath water every day. c. The patient takes diphenhydramine at night for persistent itching. d. The patient uses bacitracin-neomycin-polymyxin on minor abrasions.
d. The patient uses bacitracin-neomycin-polymyxin on minor abrasions. Neosporin can cause contact dermatitis. The patient is appropriately using the other medications.
A patient who has burns on the arms, legs, and chest from a house fire has become agitated & restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation.
d. Use pulse oximetry to check oxygen saturation. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, & this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing LOC & orientation is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.
Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)
d. hydromorphone (Dilaudid) Opioid pain medications are the best choice for pain control. The other drugs are used as adjuvants to enhance the effects of opioids.
