Med Surg-Skin & Pressure Ulcer Questions
The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 g0 1200 mg. What is the total daily dosage that Aaron will be receiving?
1200mg 600 q12h = 600 * 2 = 1200 mg
The nurse plans to administer a prescribed does of linezolid (ZYVOX), an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The prescribed states, "ZYVOX suspension 600 mg PO q12h for 14 days." The medication is labeled, "100 mg/5 ml)." How many mL of medication will the nurse administer?
30 mL 600mg x (5mL/100 mg) = 30 mL
A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
A client with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times a day for 7 days. Terconazole and tioconazole are used to treat vulvovaginal candidiasis. Sulconazole nitrate is used to treat tinea versicolor.
A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?
A potent topical corticosteroid may increase the client's risk for injury because it may be absorbed percutaneously, causing the same adverse effects as systemic corticosteroids. Topical corticosteroids aren't involved in significant drug interactions. These preparations cause vasoconstriction, not vasodilation. A potent topical corticosteroid rarely is prescribed for use on the face, neck, or intertriginous sites because application on these areas may lead to increased adverse effects.
A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
A scale is the characteristic secondary lesion occurring in psoriasis. Although crusts, ulcers, and scars also are secondary lesions in skin disorders, they don't accompany psoriasis.
A male client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe
Although many drugs are used to treat skin disorders, topical agents — not I.V. or oral agents — are the mainstay of treatment.
After receiving the first ZYVOX, Aaron develops a rash and itching on his thorax, but no respiratory symptoms. Which class of medication should the nurse expect to administer?
An antihistamine, such diphenhydramine (Benadryl)
Prior to administering the first does of the antibiotic, the nurse asks Aaron about any drug allergies. The nurse explains to Aaron that this precaution reduces the risk for what potential problem?
Anaphylactic reaction
Which intervention is important to reduce the effect of the diarrhea on Aaron's skin?
Apply a moisture-repellent ointment on intact skin areas.
The nurse observes that the reddish area is round, 3 cm diameter, and is directly over the client's sacrum. The skin is intact. In addition to measuring the length of the time the redness lasts, which assessment measure should the nurse perform?
Apply light pressure to the area with the fingertips. (to see if it blanches)
After assessing for sinus tracts, the nurse irrigates the wound using high pressure as prescribed with normal saline. Which irrigation technique is best?
Apply steady pressure using a 35 ml syringe and 19-gauge needle . Be sure to always clarify if order is for high or low pressure irrigation. (High-pressure lavage, usually performed using syringes and needles, is 35-70 pounds per square inch (psi), and low-pressure irrigation is 1-15 psi, typically using a bulb syringe, as defined by the American College of Surgeons. Seminal studies of high-pressure pulsating jet lavage (70 psi) indicated it is more effective in reducing bacterial populations and removing necrotic tissue and foreign particles versus bulb syringe and other low-pressure systems. However, especially in chronic wounds, high pressure irrigation systems have been shown to damage granulation and epithelial tissue or cause discomfort to the patient. In all wounds, high pressure may also drive bacteria into deeper compartments, causing increased risk of infection, particularly in highly vascularized areas such as the scalp and face. In summary, the benefits of higher pressures in reducing bacterial count, dirt, and tissue debris in heavily contaminated wounds may outweigh the risk of tissue injury. In relatively clean wounds, the potential damage of tissue resulting from high-pressure irrigation may outweigh the benefits.) It is important to note the date of opening a saline container, as bacterial growth in saline may be present within 24 hours of opening the container.
Dr. Smith prescribes an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
Applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer. Although emollients make the skin feel soft, this effect occurs whether or not the client has just bathed or showered. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient doesn't prevent skin inflammation.
The home care nurse teaches Aaron about dietary measures to promote wound healing and emphasizes the need for extra protein. The nurse encourages him to select which breakfast items to provide a good source of protein?
Eggs and orange juice
Upon learning that Aaron has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take?
Encourage him to continue to use this device in his wheelchair at all times. Never use a donut shaped foam cushion as it decreases blood supply to central area.
A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is deep red around the edge. The nurse takes which action first?
Following breast reconstruction, the flap is inspected for color, temperature, and capillary refill. Assessment of the nipple areola is made, and dressings are designed so this area can be observed. An areola that is deep red, purple, dusky, or black around the edge is reported to the physician immediately because this may indicate a decreased blood supply to the area. The nurse would also document the findings once the physician is notified. Options B and C are incorrect actions.
A wound culture indicates that Aaron's wound is infected with MRSA. Wound care prescribed by the healthcare provider includes wound irrigation. Which protective equipment will the nurse use when providing the prescribed wound care?
Gloves, gown, goggles, face mask . There is the possibility of splashing while irrigating.
The nurse identifies that Aaron has developed a Stage I pressure ulcer. The nurse is concerned that Aaron may have other pressure ulcers. Which areas are most important for the nurse to observe for additional pressure ulcers?
Heels and ankles
A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature delivery. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.
The home care nurse observes that Aaron's ulcer is red, with obvious granulation tissue filling in the ulcer crater. What teaching should the nurse provide?
Hydrocolloid dressings should be continued over the ulcer. Once the wound is clean and granulation tissue is observed, the dressing is typically changed to a hydrocolloid to keep wound moist to promote healing.
The nurse identifies a priority problem for Aaron's plan of care as "Impaired skin integrity". What etiology should the nurse identify?
Impaired physical mobility
When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care
Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication. The client's nails should be kept trimmed to avoid scratching; however, mitts aren't necessary. Topical antibiotics are less effective than systemic antibiotics in treating impetigo.
A female client sees a dermatologist for a skin problem. Later, the nurse reviews the client's chart and notes that the chief complaint was intertrigo. This term refers to which condition?
Intertrigo refers to irritation of opposing skin surfaces caused by friction. Spontaneously occurring wheals occur in hives. A fungus that enters the skin surface and causes infection is a dermatophyte. Inflammation of a hair follicle is called folliculitis
Which nursing intervention can help a client maintain healthy skin?
Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.
Following wound irrigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing?
Mechanically debride the tissue. Wet to dry dressing is now controversial. Using a wet-to-dry dressing involves placing moist saline gauze onto the wound bed, with a dry gauze over it, then allowing wet gauze to dry and adhere to the tissue in the wound bed. Once the gauze is dry, the clinician removes the gauze, with force often required. This has to be repeated every 4 to 6 hours. Wet-to-dry dressings are a nonselective debridement method that can harm good tissue as well as remove necrotic tissue. It keeps the wound bed at a cool temperature and it at risk for bacterial invasion, as bacteria can penetrate up to 64 layers of gauze! It's a painful procedure for the patients. [ In contrast, absorbent dressing materials (hydrogel dressing) keep a wound moist]
No evidence of drug toxicity is found. The wound eschar has all been removed, and there is no further drainage. A hydrocolloid dressing is placed over the wound, and Aaron is discharged. Aaron will complete the 2-week antibiotic treatment at home. The home care nurse visits Aaron a week after discharge to assess the wound. The nurse reviews symptoms of pressure ulcers with Aaron as well as when to call the healthcare provider. Aaron yells the nurse and says, "I don't need a nurse to tell me that I will spend the rest of my life in and out of hospitals!" What initial action should the nurse take?
Offer Aaron the opportunity to discuss his feelings of anger and hopelessness
The nurse teaches Aaron to apply a transparent film dressing over the sacral area and advises him to follow which schedule for dressing changes?
Once weekly (Transparent dressings: Tegaderm, Opsite) Transparent film dressings are clear so you can see the wound through them. This type of dressing is used to protect skin in pressure spots. It can also be used to cover wounds with little or no drainage. It helps keep moisture in the wound to aid healing. No other dressing is needed to cover the film. The dressing is changed every 5-7 days. It may need to be changed more often if it gets bunched up or the edges roll and no longer stick. It is not used for wounds that need to be changed daily. It should not be used on frail skin because it can tear the skin when it is removed.
A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause:
Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting. It isn't associated with palpitations, dizziness, or a metallic taste.
Before pouring the suspension, the nurse determines that the medication and dose on the bottle's label are correct as prescribed, but the client name listed on the bottle is incorrect. Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?
Pharmacist. The pharmacist is responsible for delivering correct med as prescribed
The nurse correctly uses which technique when pouring the suspension?
Place the medication cup on a flat surface at eye level
The nurse observes that the sacral ulcer is open, has a crater-like appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. Aaron is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. What documentation best describes the drainage from Aaron's wound?
Purulent. Exudate ( drainage) commonly seen with wounds.: • Serous: clear, amber, thin and watery • Fibrinous: cloudy and thin, with strands of fibrin • Serosanguineous: clear, pink, thin and watery • Sanguineous: reddish, thin and watery • Purulent: opaque, milky; sometimes green (pus) • Hemorrhagic: red, thick
Nurse Meredith is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?
Rings or donuts aren't to be used because they restrict circulation. Foam mattresses evenly distribute pressure. Gel pads redistribute with the client's weight. The water bed also distributes pressure over the entire surface.
The nurse suspects that Aaron's wound has developed a sinus tract, or tunneling. What equipment will the nurse use to assess the length of the tract?
Sterile cotton-tipped applicator. This is inserted into the wound, and then length measured after removal.
A male client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage?
Sunscreen should be applied even on overcast days, because the sun's rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn't guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun's rays onto the skin.
A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug?
The most significant adverse reactions to gentamicin and other aminoglycosides are ototoxicity (indicated by vertigo, tinnitus, and hearing loss) and nephrotoxicity (indicated by urinary cells or casts, oliguria, proteinuria, and reduced creatinine clearance). These adverse reactions are most common in elderly and dehydrated clients, those with renal impairment, and those receiving concomitant therapy with another potentially ototoxic or nephrotoxic drug. Gentamicin isn't associated with aplastic anemia, cardiac arrhythmias, or seizures.
Nurse Rudolf documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing?
The scab formation is found in the migratory phase. It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound. In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue. During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound. In the maturation phase, cells and vessels return to normal and the scab sloughs off.
A nurse is doing a dressing change on a venous stasis ulcer that is clean and has a growing bed of granulation tissue. The nurse avoids using which of the following dressing materials on this wound?
The use of wet-to-dry saline dressings provides a nonselective mechanical debridement, whereby both devitalized and viable tissue are removed. This method should not be used on a clean, granulating wound. Granulation tissue in a venous stasis ulcer is protected through the use of wet-to-wet saline dressings, Vaseline gauze, or moist occlusive dressings, such as hydrocolloid dressings.
Nurse Troy discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should
To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client's condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn't require enteric precautions because the mites aren't found on feces.
When the medication bottle is properly relabeled, the nurse mixes the suspension prior to pouring it. Which technique should the nurse use to mix the ZYVOX?
Turn the bottle upside down 3 to 5 times
While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?"
When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he's symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
A male client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be
With a superficial partial thickness burn such as a solar burn (sunburn), the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.
The sacral area has remained red for two hours and does not blanch when tested. How will the nurse document this finding?
"Reactive" hyperemia This is increased blood in a part ( causing redness) resulting from the restoration of its temporarily blocked blood flow./ "ischemia" (from pressure)
Aaron states, "I'm sorry I yelled at you, but I'm so discouraged about this bed sore and the infection." How should the nurse respond to Aaron's statement?
"You are trying to cope with a lot of concerns right now."
12.The nurse prepares a written positioning schedule and places it in Aaron's room as a reminder for the UAP assigned to help with Aaron's care. The charge nurse removes the schedule and states that it violates Aaron's privacy. What action should the nurse take?
Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights
After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal will the nurse include in Aaron's plan of care?
Client's skin will remain intact
During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement?
Identify these areas as sites where pressure damage has occurred. Stage 1 pressure ulcers have red, warm and spongy-textured areas on the skin.
At the end of the appointment, the nurse provides client teaching about measures to promote healing and prevent further tissue destruction. To provide pressure relief at night, the nurse teaches Aaron to sleep in which position?
Thirty-degree lateral inclined position. Full side-lying position with 90 degree bend of knees would put pressure on another bony prominence. Supine puts pressure over already injured tissue.
Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest How should the nurse apply this topical agent
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.
