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

Ensure that the solution is freshly prepared before use.

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

Weeping of the skin

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

White skin that is insensitive to touch

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

"I should never wear warm clothing over the newly healed skin area."

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

"I will apply the ointment once a day and cover it with a sterile dressing."

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

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

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

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

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

"The exact cause of acne is not known."

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

"The local anesthetic may cause a burning or stinging sensation."

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

1.A client who is underweight 3.A client diagnosed with heart failure 4.A client diagnosed with spinal cord injury

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

1.Apply cool water to the area. 4.Wrap burned fingers separately to prevent sticking together. 5.Cover the burns with a clean dry cloth as directed by a burn center.

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

1.Palpation 2.Induration

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

1.Wound culture 2.Antibiotic therapy 4.Warm compresses

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

1.Wound from repair of a perforated appendix 3.Gunshot wound that punctured the small intestine 4.Sterile wound resulting from a total radical mastectomy 5.Traumatic wound to the abdomen and intentionally left open for several days 6.Wound related to debridement of a chronic pressure injury resulting in a cavity-like defect

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

2.Clean with mild soap and water. 3.Encourage adequate nutritional intake. 5.Apply a dressing that allows oxygen to pass through.

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

2.Knees 3.Elbows 5.Base of the spine

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

2.Nails for shape, contour, color, thickness and cleanliness 3.Skin for color, integrity, scars, lesions, and signs of breakdown 4.Facial and body hair for distribution, color, quantity and hygiene 5.Skin temperature, texture, moisture, thickness, turgor, and mobility

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

3.Administering pain medications as prescribed 5.Monitoring the donor site and the graft site for signs of infection

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

3.Apply sunscreen liberally 15 to 30 minutes before sun exposure. 4.Use a sun protection factor (SPF) of at least 30 with UVA and UVB protection. 5.It is best to avoid exposure to the sun during the day between 10:00 am and 4:00 pm.

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

3.It is highly metastatic. 5.Lesion is a nevus that has changed in color.

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

36%

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

4.The allergen will be placed on the skin and covered with an airtight dressing. 5.A negative reaction occurs when there is no erythema, swelling, or complaint of itching.

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

A client with a lowered mental awareness status

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

Ambulation three times daily

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

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

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

Appearance

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

Appearance of reddish-blue lesions on the lower extremities

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

Autograft

The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse assesses a rash on the client's face. What is the name of the major skin manifestation of discoid lupus erythematosus (DLE) and SLE?

Butterfly rash

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

Can stain the skin and hair

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

Characteristic of a thrush infection

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

Chicken breast, broccoli, strawberries, milk

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

Elevating and immobilizing the affected leg

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

It is caused by a tick carried by deer.

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

It provides better cosmetic results.

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

Partial-thickness skin loss of the epidermis

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

Red, shiny skin around the nail bed

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

Silvery-white scaly lesions

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

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

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

Venous circulation is being impaired.

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

normal saline

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

A white color of the skin which is insensitive to touch

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

Neurological deficits

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

2.Use sunscreen when participating in outdoor activities. 3.Wear a hat, opaque clothing, and sunglasses when in the sun. 5.Examine your body monthly for any lesions that may be suspicious.