EAQ: Tissue Integrity

A nurse in the pediatric clinic is taking the health history of a toddler with an exacerbation of eczema. What are the nurse's priority assessments of the child? Select all that apply. 1 Increase in appetite 2 Wearing cotton clothes 3 Tolerance of new foods 4 Exposure to a viral infection 5 Recent contact with someone with eczema

2,3

A nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. Which type of graft is going to be applied by the health care provider? 1 Isograft 2 Allograft 3 Homograft 4 Heterograft

4

A 10-year-old child sustains partial-thickness burns of the entire right arm and hand, upper anterior left arm, and anterior chest. The nurse calculates the percent of total body surface area (TBSA) burned with the use of the modified "rule of nines." What percentage of the child's body is burned? 1 20% 2 24.5% 3 30% 4 36.5%

2

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss? 1 Blood urea nitrogen (BUN) 2 Blood pH 3 Hematocrit 4 Sedimentation rate

3

A health care provider tells a client that vitamin E and beta-carotene are important for healthier skin. Which foods should the nurse recommend that are excellent sources of both of these substances? 1 Spinach and mangoes 2 Fish and peanut butter 3 Oranges and grapefruits 4 Carrots and sweet potatoes

1

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply. 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence

2,3,4,5 age is not used in the braden scale.

A nurse is caring for a group of clients who are being considered for treatment with a negative pressure wound treatment device. The nurse should discuss this prescription with the primary health care provider when the client has which condition? 1 Neuropathic ulcer 2 Abdominal dehiscence 3 Stage IV pressure ulcer with eschar 4 Treated osteomyelitis within the vicinity of the wound

3

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. What information about burns should guide the nurse's plan of care? 1 Burns are extremely painful and disfiguring. 2 Some grafting of the burned area is necessary. 3 Pressure dressings and prolonged hydrotherapy are required. 4 Spontaneous epithelial regeneration occurs within several weeks.

4

A client who sustained serious burns now has a stress ulcer. When caring for this client, what clinical indicators should the nurse immediately report to the health care provider? Select all that apply. 1 Weakness 2 Diaphoresis 3 Tachycardia 4 Cold extremities 5 Flushed skin tone

1,2,3,4

When reestablishing a portable wound drainage system after emptying its contents, the reason that the nurse should squeeze the collection container and recap the drain is to: 1 Establish positive pressure 2 Decrease negative pressure 3 Maintain atmospheric pressure 4 Increase the difference in pressure

4

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound? 1 In the preoperative period 2 Two days before discharge 3 On the first postoperative day 4 During the first dressing change

1

An adult client sustains partial- and full-thickness burns of the left thigh, left arm, and head. Using the Lund-Browder chart, the nurse calculates that the percentage of total body surface area burned is: 1 16.5% 2 23.5% 3 28.5% 4 30.5%

2

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube with a high-volume, low-pressure cuff. What problem is prevented when the nurse uses a high-volume, low-pressure cuff? 1 Air leakage 2 Lung infection 3 Mucosal necrosis 4 Tracheal secretion

3

When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle? 1 Wound asepsis 2 Medical asepsis 3 Surgical asepsis 4 Concurrent asepsis

3

A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will: 1 Cut my toenails before bathing." 2 Soak my feet daily for one hour." 3 Examine my feet using a mirror at least once a week." 4 Break in my new shoes over the course of several weeks."

4

A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment device has been prescribed to hasten wound healing. Which nursing action is most appropriate when caring for this client? 1 Replace the wound sponge every 48 hours 2 Change the dressing using sterile technique 3 Overlap the edges of intact skin with the sponge 4 Set the negative vacuum pressure at 240 mm Hg

1

A client has an abdominoperineal resection. Which position should the nurse encourage the client to assume to promote perineal wound healing? 1 Sims 2 Side-lying 3 Knee-chest 4 Dorsal recumbent

2

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? 1 Change the dressing. 2 Reinforce the dressing. 3 Replace the tape with Montgomery ties. 4 Support the incision with an abdominal binder.

2

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in: 1 Serum sodium 2 Urinary output 3 Hematocrit level 4 Serum potassium

2

The nurse identifies silvery scales on a client's elbows and knees. To help identify the origin of this rash, the nurse should assess the client's history of: 1 Using a harsh, irritating soap 2 Stress in recent months 3 Excursions into uncultivated, weedy areas 4 Infection with the human immunodeficiency virus (HIV)

2

When changing the dressings on deep partial-thickness burns on a client's hand, the nurse should use what type of gauze and what technique? 1 Cotton-backed; fully extending the fingers with thumb in opposition 2 Non-cotton-backed; placing a hand roll with gauze between each finger 3 Non-cotton-backed; extending fingers fully with gauze between each finger 4 Cotton-backed; a hand roll, with fingers completely flexed and thumb in opposition

2

A client has a deep soft tissue injury that is open and oozing blood. How should the nurse care for the wound? 1 Replace the dressing when it is completely saturated 2 Reinforce the dressing several times before changing it 3 Change the dressing each time the blood oozes through the outside layer 4 Pack the wound with antimicrobial gauze each time the dressing is changed

3

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for: 1 Changes in the chest x-ray findings 2 Sputum that contains particles of blood 3 Nasal discharge containing carbon particles 4 Changes in the arterial blood gases consistent with acidosis

3

A client who has an above-the-knee amputation is fitted with a prosthesis. The nurse evaluates the client's response to the prosthesis. Which indicates that the prosthesis fits the residual limb correctly? 1 Absence of phantom limb sensation 2 Uneven wearing down of the heels of the shoes 3 Shrinkage of the end portion of the residual limb 4 Darkened skin areas surrounding the end of the residual limb

4