Concepts unit 2 - Tissue Integrity
A nurse is planning care for a client who has a new prescription for methotrexate. The nurse should plan to monitor the client for which of the following adverse effects? A - Bone marrow depression B - Thrombocythemia C - Double vision D - Constipation
A - Bone marrow depression
A nurse should instruct a client who is taking alendronate to monitor for which of the following adverse effects (Select all) A - Jaw pain B - Drowsiness C - Blurred vision D - Tinnitus E - Muscle pain
A - Jaw pain C - Blurred vision E - Muscle pain
The nurse working in a ped's office receives a call from a mother asking for advices about how to treat her child. Who was found to have had lice A - Wash the child's hear with Rid B - Comb with a fine-tipped comb dipped in alcohol C - Pick off any nits that remain on the hair shaft D - Wash all bedding in very hot water E - Isolate the child from others for one week.
A - Wash the child's hear with Rid C - Pick off any nits that remain on the hair shaft D - Wash all bedding in very hot water
A nurse is teaching a client who is taking etanercept for RA. The nurse should instruct the client to monitor which of the following indications of an adverse reaction to this drug? A - skin rash B - tinnitus C - diarrhea D - dysphagia
A - skin rash
The nurse identifies the following patient who would be at the greater risk for use of heat and cold applications A- 68-year-old client with advanced Alzheimer's disease B- 42 year old recently diagnosed with diabetes mellitus C- 24- year old with RA (WRONG) D - 12 year old with new fractured right humerus
A- 68-year-old client with advanced Alzheimer's disease
A nurse is caring for a client who has widespread psoriasis. The nurse should prepare the client for which of the following treatments. A - Radiation therapy B - Exposure to photo-chemotherapy C - Topical application of antibiotic ointment D - Administration of isotretinoin.
B - Exposure to photo-chemotherapy
If a wound appears infected, you should A - Cleanse it with an antiseptic solution B - Obtain an order for a culture to be preformed C - Apply an antibiotic ointment D - Change the dressing ever 2 hours.
B - Obtain an order for a culture to be preformed
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take? A - feed the infant through an NG tube B - Place the infant in prone position C - Cover the infant's lesion with a dry cloth D - Perform range-of-motion (ROM exercises to the infant's hip.
B - Place the infant in prone position
The nurse is reviewing a care plan for the client at risk for pressure ulcers. Appropriate interventions include A - Providing a high carb, low protein diet B - Scrubbing the skin with minimal force and friction C- Position head of bed no more that 45 degrees D- Use a trapeze when lifting a client to change positions E - Change wound dressings three to four times a day Appropriate nutritional support includes adequate calories, protein
B - Scrubbing the skin with minimal force and friction D- Use a trapeze when lifting a client to change positions
A nurse is caring for a client who is currently taking methotrexate for RA. The nurse should identify that which of the following is an adverse effect of this medication? A - Hypertension B - Thrombocytopenia C - Glaucoma D - Edema
B - Thrombocytopenia
The nurse working in an emergency outpatient clinic admits a diabetic client with an irregular shaped red are on the calf of the leg that is hot to touch, painful and edematous with red streaks found traveling from the red area up the back of the thigh The nurse anticipated what diagnosis A - Venous stasis ulcer B- Cellulitis C - Peripheral vascular disease D - Gangrene
B- Cellulitis
The nurse responds to a patient call light and the patient stats that while coughing their surgical wounds opened up with stuff walling through. The nurse anticipates which complication of wound healing A - Hemorrhage B - Infection C - Evisceration D - Dehiscence
C - Evisceration
A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take? A - Massage the client's bony prominences B - Keep the head of the bed elevated C - Reposition the client at least every 2 hrs. D - Keep the client's skin moist.
C - Reposition the client at least every 2 hrs.
A nurse is assisting with the development of a teaching plan for a client who has psoriasis. Which of the following statements should the nurse include in the plan? A - Wash the affected areas with hot water B - Treatment will focus on pain management C - Treatment will include coal tar preparations D - Apply warm moist compresses to the affected areas.
C - Treatment will include coal tar preparations
The nurse caring for a comatose client does which of the following to prevent a pressure ulcer on the back of the client's head A - Places a small pillow under the client's shoulders B - Places the client in the prone position several times a day C- Uses a gel floatation pad directly under the occiput when supine D- Consistently turn the client's head to the right
C- Uses a gel floatation pad directly under the occiput when supine
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of a latex allergy. Which of the following statements by the client indicated an understanding of the teaching? A - "I will apply an elastic bandage to a cut" B - "When cleaning, I like to use dishwashing gloves." C - "On my son's birthday I plan to by balloons." D - "I will use ink pens for writing."
D - "I will use ink pens for writing."
A nurse is reviewing the plan of care for a client who is postoperative following colon resection. Which of the following interventions should the nurse expect to implement? A - Have the client use the incentive spirometer every 4 hrs while awake B - Begin ambulation on the third postoperative day C - Provided regular nutrition through a nasogastric tube. D - Assist the client to splint the incision while coughing.
D - Assist the client to splint the incision while coughing.
A nurse is caring for a client who has a prescription for methotrexate. Which of the following drugs would likely be prescribed in conjunction during the initial treatment for RA. A - Aspirin B - Salicylates C - Sulfonylureas D - Ibuprofen
D - Ibuprofen
Upon inspection of a client's skin, a nurse identifies a state 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a state 3 pressure ulcer? A - There appears to be persistent reddening of the skin B - There is slough on part of the wound area C - There is a fluid-filled area under the skin D - There is full-thickness skin loss with a crater.
D - There is full-thickness skin loss with a crater.
A nurse is assisting with the admission of a client who has an open wound that is infected from community-acquired methicillin-resistant staphylococcus aureus. (CA-MRSA). The client's wound has not responded to treatment with surgical drainage. The nurse should anticipate that the client will require which of the following interventions? A - Droplet precautions B - Penicillin G C - Airborne precautions D - Trimethoprim/Sulfamethoxazole
D - Trimethoprim/Sulfamethoxazole
A nurse is teaching a client who has a prescription for calcitonin-salmon about manifestations of hypercalcemia. Which of the following manifestations should the nurse include in the teaching? A - Muscle twitching B - Fever C - Nervousness D - Vomiting
D - Vomiting
A nurse is reinforcing medication teaching with a client who has psoriasis and a new prescription for triamcinolone cream. A - Creams should be applied in a thick layer to completely cover the lesions. B - Expect to see darkened areas of skin where the cream is applied C - Rubbing the medication vigorously into the lesions will increase absorption D - Wrapping plastic around the site can increase the medication's effectiveness
D - Wrapping plastic around the site can increase the medication's effectiveness
A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection? A - Initiate protective isolation B - Allow the wound to air periodically C - Clean the incision with soap and water D .- Perform hand hygiene prior to dressing changes.
D .- Perform hand hygiene prior to dressing changes.
A nurse is teaching a client about adverse effects of etanercept. Which of the following statements by the client indicates understanding of the teaching? A - "I will need to get my blood drawn periodically while on this medication" B - "I may lose part or all of my hair" C - "I may wake up with a very dry mouth" D - "I will leave the needle cap off during the time the medication comes to room temp"
A - "I will need to get my blood drawn periodically while on this medication"
A nurse is teaching a client about methotrexate therapy for RA. Which of the following information should the nurse include (Select All) A - Avoid being near people who are sick with a communicable illness B - Periodic laboratory tests are required C - The drug's effects are immediate D - Report bruising or petechiae E - Avoid drinking alcohol
A - Avoid being near people who are sick with a communicable illness B - Periodic laboratory tests are required D - Report bruising or petechiae E - Avoid drinking alcohol
The nurse is reviewing the lab results from the previous day for a hospitalized client following a motor vehicle accident which resulted in extensive wounds and noticed that the client total protein levels are low. A - Baked chicken, red beans , brown rice, skim milk and fresh fruit. B - Fried chicken, spinach salad, whole milk, fruit C - Veal chops, tossed salad, squash casserole, whole milk, peach cobbler D - Baked chicken, cole slaw, mixed vegetables, diet soda, apple
A - Baked chicken, red beans , brown rice, skim milk and fresh fruit.
A nurse is reinforcing infection control practices for hand hygiene with a group of unit nurses. Which of the following information should the nurse reinforce in the teaching? A - Change gloves between tasks on the same client B - Keep artificial nails trimmed should C - Use alcohol-bases hand rubs before administering eye drops for a client D - Wash hands with alcohol-bases hand rubs when caring for client who has clostridium difficile
A - Change gloves between tasks on the same client
The nurse monitors for complications on a post-appendectomy patient who has RA and takes aspirin for joint pain, anticipating which of the following A - Delayed healing form the use of aspirin B - Increased pain levels due to the arthritis C - Pneumonia due to immobility D - Joint contractures due to immobility
A - Delayed healing form the use of aspirin
The nurse is talking a client's history on admission to a rehabilitation facility. Factors that may cause skin integrity to be impaired in a 45 year old post- surgical client A - Genetics B - Use of antibiotics C - Poor nutrition D - Intact skin E - Restricted mobility
A - Genetics C - Poor nutrition E - Restricted mobility
A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressing should the nurse apply to the wound? A - Transparent B - Wet-to-Dry C - Dry, sterile D - Antimicrobial
A - Transparent
A nurse is reinforcing teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins should the nurse include in the teaching as promotion wound healing. (Select all) A - Vitamin A B - Vitamin B12 C - Vitamin C D - Vitamin D E - Vitamin E
A - Vitamin A C - Vitamin C
A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients? A - Vitamin C B - Niacin C - Iron D - Potassium
A - Vitamin C
A nurse at a community center is assisting with a presentation about sun protection to a group of residents. Which of the following responses by the residents indicated an understanding of the teaching? A - "Sunscreen does not need to be applies on a cloudy day." B - "I should apply a sunscreen with an SPF of 30" C - "A sunscreen is a better choice for my toddler than a sunblock D - "I can expose my 3 month-old intact to the sun if i apply sunscreen>
B - "I should apply a sunscreen with an SPF of 30"
A nurse is teaching a client who has a new prescription for etanercept. Which of the following statements should the nurse make? A - "You will inject this medication once a week in your thigh muscle." B - "You should report signs of infection to your provided immediately.: C - "You will need to avoid taking ibuprofen while on this medication." D - "You will need to receive a MMR vaccine 1 moth after starting this medication."
B - "You should report signs of infection to your provided immediately.:
A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection. A - A client who has serosanguineous drainage from the wound. B - A client who has swelling and tenderness around the wound. C - A client who has urticaria and itching around the wound D - A client who has a brown crusting over the wound.
B - A client who has swelling and tenderness around the wound.
A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection? A - Petechiae B - Edema C - Urticaria D - Crusting over granulated tissue
B - Edema
Your pt has had abdominal surgery for a ruptured appendix and requires postoperative care and dressing changes. The wound has been left open, and irrigations are ordered. When irrigating a wound, it is most important to: A - Irrigate slowly to prevent discomfort B - Ensure the solution reaches the depths of the wound C - Prevent wetting of the bed and covers D - Use vigorous irrigation flow from the syringe
B - Ensure the solution reaches the depths of the wound
A nurse identifies a pressure ulcer after a client has a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, which fo the following actions should the nurse take? A - Document what the nurse believes was the cause of ulcer development B - Include any relevant statements the client made about the incident. C - Document in the client's medical record that she completed an incident report D - Question the charge nurse about care deficits that might have contributed to the incident.
B - Include any relevant statements the client made about the incident.
A nurse is teaching about self-administering methotrexate to a client who has RA. Which of the following statements should the nurse make? A - "Use a non-steroidal anti-inflammatory drug to reduce toxicity" B - "Take it with food to reduce gastric irritation" C - "Drink 2 to 3 liters of water per day to promote the drug's excretion" D - "Take it in the morning to prevent insomnia?
C - "Drink 2 to 3 liters of water per day to promote the drug's excretion"
A nurse is caring for a client who is postoperative following an abdominal hysterectomy and has an indwelling urinary catheter in place. An assistive personnel (AP) reports to the nurse that the client's abdominal dressing is saturated with blood. Which of the following tasks should be delegated to the AP A - Changing the abdominal dressing B - Obtaining vital sings C - Emptying the urinary collection bag D - Observing the incisional site
C - Emptying the urinary collection bag
Alendronate is contraindicated for administration to clients who have which of the following conditions? A - Heart failure B - Fish protein allergy C - Inability to sit upright D - TB
C - Inability to sit upright
A nurse is evaluating understanding of medicated baths for a client who has psoriasis. Which of the following client statements should the nurse identify as understanding of the information? A - "I should apply the medication to my skin 5 min before getting into the tub" B - "I will dry my skin by wiping from my extremities inward toward my torso." C - "I should use water that is about 37.2°C (99°F) for a medicated bath." D - "I will remain in the tub for 25 min."
D - "I will remain in the tub for 25 min."
A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend? A - Tuna salad B - Fresh fruit C - Vegetables D - Beans
D - Beans
A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? A - The wound is tender to touch B - The wound has pink, shiny tissue wit a granular appearance C - The wound has serosanguineous drainage D - The wound has a halo of erythema on the surrounding skin.
D - The wound has a halo of erythema on the surrounding skin.
A nurse is teaching a client about methotrexate therapy for RA. Which of the following statements by the client indicated understanding of the teaching? A - "I will take a birth control pill every day." B - "Methotrexate decreases my chances of developing an infection." C - "I take methotrexate every day with breakfast." D - "I will aim to drink five 8-ounce glasses of water per day."
A - "I will take a birth control pill every day."
The nurse conducting a pressure ulcer risk assessment on clients in long-term can facility identifies which of the following as risk factors (Select all) A - Elevated temp of 101 B - decreased response to painful stimuli C - Consumes a high-protein diet D - Drinks six glasses of water daily E - Walks occasionally for a short distance
A - Elevated temp of 101 B - decreased response to painful stimuli E - Walks occasionally for a short distance
A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicated healing of the wound? A - Granulation tissue on the surface of the wound. B - Musty odor from the foam dressing upon removal C - Sanguineous drainage in the suction device D - Peeling of the edges of the transparent dressing
A - Granulation tissue on the surface of the wound.
A nurse is teaching a client about calcitonin-salmon intranasal spray to treat osteoporosis. Which of the following information should the nurse include (Select all) A - Report rash or itching B - Deliver two sprays to each nostril C - Prime the pump before the first dose D - Report nasal irritation E - Hold the pump horizontally
A - Report rash or itching C - Prime the pump before the first dose D - Report nasal irritation
A nurse should identify that a client who has diabetes mellitus and is taking etanercept is at an increased risk for which of the following adverse effects? A - Kidney Toxicity B - Infection C - Gout D - Deep-vein thrombosis
B - Infection
The nurse admits a client who has fallen from a ladder to the ER with a deep wound on the leg. There is a blood-saturated pressure dressing on the wound. The nurse assesses the client and find a heart rate of 128 rep of 30 and BP 92/50 A - Notify the physician immediately B - Reinforce the pressure dressing and elevate the extremity C - Remove the pressure dressing, assess the wound, and apply a new dressing D - Start an IV line for the administration of fluids
B - Reinforce the pressure dressing and elevate the extremity
A nurse is teaching a client about raloxifene therapy to prevent osteoporosis. The nurse should instruct the client to monitor for which of the following indications of an adverse reaction to this drug? A - Loss of hair B - Numbness of the fingertips C - Calf pain D - Blisters on mucous membranes
C - Calf pain
A nurse is planning to change an abdominal dressing for a client who has an incision with a drain Which of the following actions should the nurse plan to take? A - Remove the entire dressing at once B - Loosen the dressing by pulling the tape away from the wound C - Don clean gloves to remove the dressing D .- Open sterile supplies before removing the dressing.
C - Don clean gloves to remove the dressing
The nurse is reinforcing instructions to the mother of a 2 year old with a diagnosis of impetigo and determines. Determines further teaching is required A - "I will apply bacitracin to the wound an cover it loosely with a bandage." B - "I will watch the wound carefully and call the doctor if it feel hot." C - "I will call the doctor if the wound doesn't improve, or gets bigger." D - "I will wash the sore daily being careful not to remove crusts"
D - "I will wash the sore daily being careful not to remove crusts"
A nurse is caring for a client who has stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care. A - Apply a heat lamp twice a day B - Cleanse with 0.9% sodium chloride irrigation C - Cleanse with povidone-iodine solution D - Massage reddened areas during dressing changes
B - Cleanse with 0.9% sodium chloride irrigation
A nurse is teaching a client about raloxifene. Which of the following information should the nurse include? (Select all) A - Performa breast self-exam twice per month B - Increase physical activity by taking walks C - Use a contraceptive is there is any possibility of pregnancy D - Take the drug on an empty stomach E - Increase intake of calcium and vitamin D
B - Increase physical activity by taking walks C - Use a contraceptive is there is any possibility of pregnancy E - Increase intake of calcium and vitamin D
A nurse is teaching a client about methotrexate. The nurse should inform the client to monitor for which of the following as an adverse effect of this drug? A - Muscle pain B - Peripheral edema C - Black, tarry stools D - Redness in the calf
C - Black, tarry stools
A nurse is caring for client who is 5 days postoperative after abdominal surgery. The client reports a sudden pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate. A - Have the client lie supine with legs straight B - Use sterile gloves to place gentle pressure on the exposed organs C - Cover the area with saline-soaked sterile dressings. D - Gently suction secretions from the wound bed using a 12 gauge sterile catheter.
C - Cover the area with saline-soaked sterile dressings.
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, "something pooped in my belly." The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next. A - Position the client supine with his hips and knees bent B - Prepare to administer an IV infusion of 0.9% sodium chloride C - Cover the wound with moist sterile gauze D - Measure the client's vital signs.
C - Cover the wound with moist sterile gauze
A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize that this is a manifestation of which of the following. A - Decreased perfusion B - Infection C - Granulation tissue D - An inflammatory response.
C - Granulation tissue Granulation tissue is soft, red tissue with a granular appearance that bleeds easily
A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity? A - Reposition the client ever 3 hrs. B - Massage bony prominences to promote circulation C - Provide the client with a diet high in protein D - Apply cornstarch to keep the skin dry.
C - Provide the client with a diet high in protein
A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown? (Select all) A - Massage erythematous bony prominences B - Implement turning schedule every 4 hr C - Use pillows to keep heels off the bed surface. D - Keep environmental humidity less than 30% E - Minimize skin exposure to moisture.
C - Use pillows to keep heels off the bed surface. E - Minimize skin exposure to moisture (Humidity should be higher than 40%)
A nurse is caring for a client who was diagnosed with postmenopausal osteoporosis. Which of the following actions should the nurse take prior to administering calcitonin- salmon to the client for the first time. A - Check the client's urine for sedimentation B - Assess the client's liver function C - Use skin testing to check the client for allergies D - Evaluate the client's breath sounds.
C - Use skin testing to check the client for allergies
A nurse is caring for a client who has a closed wound drainage system connected to a portable bulb suction device. Which of the following actions should the nurse take to care for the drain? (Select all) A - Allow the drain to fill completely before emptying B - Flush the drainage tube with sterile water each time C - Wipe the top of the drainage port with an alcohol swab after emptying D - Milk the drainage port to promote emptying E - Squeeze the suction bulb while inserting the plug into the drainage port.
C - Wipe the top of the drainage port with an alcohol swab after emptying E - Squeeze the suction bulb while inserting the plug into the drainage port.
A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer? A - Unbroken skin with un-blancheable erythema B - Full-thickness tissue loss extending to underlying support structures C - A shallow, ruptured or intact skin blister w/o slough D - A deep crater w/o visible bone, tendon, or muscle
D - A deep crater w/o visible bone, tendon, or muscle
A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include." A - Provide low-calorie snakes B - Maintain medical asepsis during dressing changes. C - Administer pain medication 30 min before physical therapy D - Allow the child to set her own schedule for care.
D - Allow the child to set her own schedule for care.
A nurse is caring for a client who is 6 days postoperative from abdominal surgery. The nurse observes that the client's wound is in evisceration. After calling for help, which of the following actions should the nurse take next. A - Raise the head of the bed B - Place the client supine with knees bent C - Assess for manifestations of shock D - Cover the area with a sterile dressing, moistened with saline.
D - Cover the area with a sterile dressing, moistened with saline.
A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take? A - Assure the client that this is an expected occurrence after surgery B - Apply an abdominal binder to the wound area. C - Turn the client onto her side D - Cover the wound with a moist sterile dressing
D - Cover the wound with a moist sterile dressing
The nurse understands that wounds in infants and children heal more rapidly because A - It is more fragile B - Their skin has not been exposed to sun C - Their skin is thinner D - Due to rapid cell division
D - Due to rapid cell division
A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A - Serosanguineous drainage B - Mild erythema C - Warmth D - Fever
D - Fever
The nurse is completing discharge instructions for the client who has a stage 2 decubitus ulcer on their foot and their spouse about care of the wound and skin assessment. The nurse concludes that the client has understood teaching if the client states which of the following? A - I will soak in the tub in hot water for 30 minutes every day B - I will call the doctor if I notice a blister anywhere on my body C - I will call the doctor if I notice a blister on a pressure point D - I will call the doctor if I feel pain or see redness over a pressure point
D - I will call the doctor if I feel pain or see redness over a pressure point
The school nurse receives a phone call from several parents reporting that their child have lice. All of the children are in the same classroom. The nurse's priority actin is to A - Assess all of the children in the classroom, and send notes home with all children in the school advising parents to check their children for lice B - Send all of the children in that class home with notes asking parents to take them to their pediatrician C - Isolate the children in the classroom and keep them from the cafeteria, gym or any place where they will come in contact with others. D - Require all students in the school to wear surgical caps until the outbreak of lice is contained.
A - Assess all of the children in the classroom, and send notes home with all children in the school advising parents to check their children for lice
A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first? A - Cover the client's wound with a moist, sterile dressing B - Have the client lie supine with knees flexed C - Check the client's vital sings D - Inform the client about the need to return to surgery
A - Cover the client's wound with a moist, sterile dressing
A nurse is reinforcing teaching with a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should she include in the teaching? (Select all) A - Cryosurgery B - Electrodessication C - Radiation therapy D - Photo-chemotherapy E - Mohs surgery.
A - Cryosurgery B - Electrodessication C - Radiation therapy E - Mohs surgery. (D used in psoriasis)
A nurse is caring for a client who is taking alendronate to treat postmenopausal osteoporosis. The nurse should explain to the client that alendronate increase bone mass by which of the following actions? A - Decrease activity of osteoclasts B - Increase calcium excretion C - Promotes intestinal absorption of calcium and phosphorus D - Reduced action of osteoblasts
A - Decrease activity of osteoclasts
A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take. A - Empty the suction device ever 4 hr B - Monitor circulation of the affected extremity every 2 hr for the first 12 hr C - Position the client's hip so that it is internally rotated. D - Encourage foot exercised every 4 hrs.
A - Empty the suction device ever 4 hr
When caring for a pressure injury, you know that A - Eschar must usually be removed before the wound will heal B - Pink granulation tissue should be cleansed with antiseptic solution C - Keeping the wound dry and covered will aid healing D - Heat treatments hurt new tissue and slow healing
A - Eschar must usually be removed before the wound will heal
The nurse anticipates the following healing process of surgical wounds A - Minimal granulation tissue and scaring B - Longer repair time C - Significant scarring D - Increased risk of infection
A - Minimal granulation tissue and scaring
The nurse is facilitating an education session for a newly LPN and emphasize that the following are manifestations that are characteristic of RA and help distinguish it from osteoarthritis A - Heberden's node B - Autoimmune disease C- Early morning stiffness D- Activity increase pain E - Involvement of other major organs F - Low-grade fever
B - Autoimmune disease C- Early morning stiffness E - Involvement of other major organs F - Low-grade fever
A nurse is caring for a client who tells the nurse he sneezed and felt his incision "give way". The nurse observes abdominal contents protruding from the incision. Which of the following actions should the nurse take. A - Place the client in a reverse Trendelenburn position B - Cover the wound with a sterile-saline-soaked towel C - Gently place the contents back within the borders of the incision D - Place an abdominal binder over the client's incision.
B - Cover the wound with a sterile-saline-soaked towel
A nurse is teaching a client who has a prescription for prednisone and takes 1,500 mg/day of calcium carbonate to reduce the risk of osteoporosis. Which of the following information should the nurse include? (Select all) A - Take the calcium tabs with food B - Drink 240 ml of water with the calcium tabs C - Chew calcium tables before swallowing them D - Take the drugs 1 hr apart E - Divided he daily dosage of calcium into three 500-mg doses.
B - Drink 240 ml of water with the calcium tabs C - Chew calcium tables before swallowing them D - Take the drugs 1 hr apart E - Divided he daily dosage of calcium into three 500-mg doses.
Which of the following is a therapeutic action of raloxifene? A - Blocks the effects of estrogen and endometrial tissue. B - Mimics the effects of estrogen on bone tissue C - Stimulates secretion of parathyroid hormone D - Stimulates menstruation
B - Mimics the effects of estrogen on bone tissue
A nurse is collecting data from a child and notes that presence of bruises on her arms and legs. Which of the following actions should the nurse take first? A - Report the suspected abuse to the authorities. B - Obtain a detailed history C - Request a social services referral D - Tell the child what will happen to her when the abuse is reported.
B - Obtain a detailed history
The nurse working in a ped's office receives a call from a mother whose child began treatment for a fungal infection two days ago. The mother is calling to report that the infection is not getting any better. The nurse's best response is A - "I'll make an appointment for your child to be seen today." B - "Are you following the directions yo were given to treat it." C - Fungal infections can take up to three weeks to resolve and at least a week before improvements is seen. D - "Your child might have a different strain of fungus, and will require antibiotics. I will speak to the doctor and call you back with the orders received."
C - Fungal infections can take up to three weeks to resolve and at least a week before improvements is seen.
A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan? A - Keep the ulcer bed dry B - Clean the wound bed with hydrogen peroxide C - Provide the client a diet high in vitamin C D - Reposition the client at least every 4 hrs.
C - Provide the client a diet high in vitamin C
A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take? A - Lightly palpate the skin using the fingertips B - Press the skin over the client's ankle bone C - Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen D - Grasp a fold of skin on the client's forearm or neat the sternum.
D - Grasp a fold of skin on the client's forearm or neat the sternum.
The nurse is assigned to care for a client with an infected four-day-old postoperative wound who has been readmitted to the inpatient unit for wound debridement and antibiotic therapy. The wound is sutured with a scab that is pulling away from the edges of the skin, is draining pus and serosanguinous fluid, and is swollen and reddened. The nurse classifies the wound at what stage of healing? A- Secondary intention healing B - Proliferative phase C - Maturation phase D - Inflammatory phase
D - Inflammatory phase
A nurse is preparing to administer alendronate to a client who has osteoporosis. The nurse should recognize which of the following as an adverse effect of alendronate? A - Venous thromboemboli B - Ventricular dysrhythmias C - Breast Cancer D - Joint pain
D - Joint pain
The assessment of the wound indicated healing is occurring when A - The center tissue is white B - Bleeding has stopped C - There is no further drainage from the wound D - Pink granulation tissue is visible
D - Pink granulation tissue is visible
A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? A - Sanguineous B - Serous C - Serosanguineous D - Purulent.
D - Purulent.
A nurse is caring for a client who is taking etanercept for RA. The nurse should monitor the client for which of the following indications for a serious adverse reaction to the drug? A - Excessive salivation B - Increased thirst C - Blood in the urine D - Shortness of breath
D - Shortness of breath
A nurse is reinforcing instructions with a client who has contact dermatitis and reports increase pruritus during the winter months. Which of the following information should the nurse include. A - Spread aloe gel or peppermint oil liberally on the skin to soothe it. B - Use fabric softener to lighten the texture of clothing. C - Rub the skin dry with a towel after washing D - Stroke itchy skin with the palm of the hand
D - Stroke itchy skin with the palm of the hand
A nurse is reinforcing teaching with the parents of a preschool child who has exanthema subitum (roseola infantum). Which of the following instructions should the nurse include. A - Apply topical calamine lotion to the rash B - Administer amoxicillin for 7 days C - Give acetaminophen chewable tables to manage fever D - Maintain strict bedrest for the child.
C - Give acetaminophen chewable tables to manage fever
When assessing for wound infection, you know that signs of wound infection may be (Select all) A - A rise in temperature B - Pink granulation tissue C - A WBC count greater than 10,000/DL D - Purulent drainage E - Tenderness around the wound
A - A rise in temperature C - A WBC count greater than 10,000/DL D - Purulent drainage E - Tenderness around the wound
A nurse is caring for a client who has a new prescription for etanercept. Which of the following actions should the nurse take? A - Administer a TB skin test prior to starting the medication B - Teach the client that fevers are common while taking this medication C - Determine if the client has chronic hypertension D - Mix the medication with methotrexate prior to administration.
A - Administer a TB skin test prior to starting the medication
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown A - Apply a moisture barrier ointment to the skin B - Clean the skin and perineum with hot water after each episode of incontinence. C - Check the client's skin every 8 hr for sings of breakdown D - Request a prescription for the insertion of an indwelling urinary catheter
A - Apply a moisture barrier ointment to the skin
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture? A - Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen B - Irrigate the wound with an antiseptic prior to obtaining the specimen C - Include intact skin at the wound edges in the culture D - Swab an area of skin away from the wound to identify normal flora
A - Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen
A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take? A - Fully recollapse the reservoir after emptying it. B - Empty the reservoir once per day C - Replace the drainage plug after releasing hand pressure on the device. D - Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
A - Fully recollapse the reservoir after emptying it.
A nurse is caring for a client who has a prescription for etanercept. The nurse should identify that etanercept treats rheumatoid arthritis by which of the following actions? A - Inactivation of tumor necrosis factor B- Inhibition of osteoclast activity C - Decreasing the reuptake os serotonin D - Interference with the production of lymphocytes.
A - Inactivation of tumor necrosis factor
The nurse applies a hydrocolloidal dressing to the client's pressure ulcer, and explains the benefits of this type of dressing as being which of the following? A - Increases client comfort B - Decreases anerobic bacterial growth C - Can be used on all wound types D - Can be molded to uneven body surfaces E - Is water-resistant
A - Increases client comfort D - Can be molded to uneven body surfaces E - Is water-resistant
A nurse is assisting with a care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg has and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds? A - Laceration B - Contusion C - Abrasion D - Puncture
A - Laceration
