CHAPT. 25

A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size Client with a white blood cell count of 23,000/mm3

ANS: C A client with an elevated white blood cell count should be evaluated for sources of infection. Pending cultures, thin drainage, and a decrease in wound size are not indications that the client may have an infection.

A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a. Viral infection Clindamycin (Cleocin) b. Bacterial infection Acyclovir (Zovirax) c. Yeast infection Linezolid (Zyvox) d. Fungal infection Ketoconazole (Nizoral)

ANS: D Ketoconazole is an antifungal. Clindamycin and linezolid are antibiotics. Acyclovir is an antiviral drug.

The nurse is evaluating the effectiveness of interventions for pressure ulcer management. Which diagnostic test result with an increased level indicates client progress and effective health care team collaboration? A. Calcium B. Hematocrit C. Numbers of immature white blood cells (WBCs) D. Serum albumin

D. Serum albumin Albumin measures protein, which is necessary for healing. Increased serum albumin indicates successful collaboration with the dietitian.Calcium, hematocrit, and WBC readings do not relate to successful pressure ulcer management.

In teaching a client about primary prevention of skin cancer, which instruction does the nurse include? A. "Avoid sun exposure between 11 a.m. and 3 p.m." B. "Examine your skin quarterly for possible cancerous or precancerous lesions." C. "Keep a total body spot and lesion map." D. "If you feel you must tan, use a tanning bed."

A. "Avoid sun exposure between 11 a.m. and 3 p.m." The nurse teaches the client that the sun's rays are strongest between 11 a.m. and 3 p.m. and can cause more damage during this time.Skin should be examined at least monthly. A total body spot and lesion map is used for secondary prevention. The rays in tanning beds are just as harmful to skin as the sun's rays and should be avoided.

Which statement by a client with psoriasis indicates to the nurse that additional teaching about the client's condition is required? A. "A tanning bed will supply the ultraviolet light I need." B. "Medicine can prevent the growth of new skin cells." C. "I can never be cured." D. "Stress can cause my flare-ups."

A. "A tanning bed will supply the ultraviolet light I need." Ultraviolet radiation is commonly used in the treatment of psoriasis, but the use of commercial tanning beds is specifically not recommended for these clients. This statement indicates that the client requires further teaching.Topical corticosteroids, when applied to psoriatic lesions, suppress cell division. Psoriasis is a lifelong disorder that has exacerbations and remissions and cannot be cured. Stress can indeed exacerbate psoriasis.

A client with a bacterial skin infection is being taught home care for treatment of this infection. Which statement by the client indicates a need for further teaching? A. "I may stop using the topical antibiotic when the lesions disappear." B. "I will remove crusts with soap and water before applying the medication." C. "I should contact my provider if I develop a fever or if the lesions spread. D. "I should cover the lesions if necessary to limit exposure to other people."

A. "I may stop using the topical antibiotic when the lesions disappear." The statement by the client that, "I may stop using the topical antibiotic when the lesions disappear," indicates the need for further teaching. The antibiotic should be used for the time prescribed and not just until the lesions seem to be resolved.Clients should be taught to remove crusts before applying the medication to improve absorption. If signs of systemic disease occur, the client should contact the provider since oral antibiotics may be necessary. Covering the lesions will help prevent spread to others.

The nurse is teaching a client about decreasing the risk for melanomas and other skin cancers. Which primary prevention technique is most important for the nurse to include? A. Avoiding or reducing skin exposure to sunlight B. Avoiding tanning beds C. Being aware of skin markings and performing skin self-examination D. Wearing SPF 40 sunscreen

A. Avoiding or reducing skin exposure to sunlight Avoiding or reducing one's exposure to the sun is the most important prevention technique. This includes avoiding direct sunlight, using sunscreen, and wearing protective clothing (including hats). It is more important to teach about avoiding sunlight because one can be exposed to sunlight daily.Avoiding tanning beds is significant, but is not the most important technique. Assessing the skin is a secondary prevention. Wearing sunscreen is essential, but reducing overall exposure to the sun is more important.

A client has an odorous, purulent wound. How does the nurse best support this client? A. Changes the dressing frequently B. Encourages a diet high in protein C. Suggests whirlpool therapy D. Places room deodorizers in the room

A. Changes the dressing frequently The nurse knows that frequent dressing changes help with healing and help the client feel clean. This is the best method of support for this client.A diet high in protein would not be directly helpful for this client. Whirlpool therapy may not be appropriate for this client. Room deodorizers do not address the source of the problem and may be offensive to the client and the family.

A client with a foot ulcer says, "I feel helpless." What is the nurse's best response? A. Encourages participation in care of the wound B. Encourages visitors C. Says, "I know how you feel" D. Assures the client that it will be all right

A. Encourages participation in care of the wound The nurse's best response is to encourage client participation in wound care. This gives the client a sense of autonomy.Encouraging visitors is not the best suggestion for this client. By telling the client that he or she understands the client's feelings, the nurse not only fails to address the underlying issue but also is patronizing. Assuring the client that everything will be all right not only fails to address the underlying issue, but also may be untrue.

The nurse anticipates that a client with a deep necrotizing wound caused by a brown recluse spider bite may require which type of healing therapy? A. Hyperbaric oxygen B. Nutrition therapy C. Topical growth factors D. Vacuum-assisted wound closure

A. Hyperbaric oxygen Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening wounds such as burns, necrotizing soft tissue infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers.Nutrition therapy can be implemented for all types of wound healing. Topical growth factors are typically used for clean, surgically débrided chronic wounds. Vacuum-assisted wound closure is typically used with chronic ulcers.

The nurse is teaching a client who has loss of sensation and movement in the lower extremities secondary to spinal cord injury about protecting skin integrity. Which daily prevention strategy does the nurse include in the client's teaching plan? A. Lift hips off the chair at least every hour. B. Eat a low-fat, low-protein diet. C. Massage reddened areas several times daily. D. Complete a pressure map to identify areas of concern.

A. Lift hips off the chair at least every hour. The daily prevention strategy the nurse includes in the client's teaching plan is that the client will lift the hips off the chair at least every hour to relieve pressure and help prevent pressure ulcers.Eating a low-fat diet is not a daily prevention strategy for skin integrity. Reddened areas should never be massaged. Pressure mapping is not a daily activity and is not performed by the client.

A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? a. You can use tap water instead of sterile saline to clean your wound. b. If you dont clean the wound properly, you could end up in the hospital. c. Sterile procedure is necessary to keep this wound from getting infected. d. Good hand hygiene is the only thing that really matters with wound care.

ANS: A For chronic wounds in the home, clean tap water and nonsterile supplies are acceptable and serve as cheaper alternatives to sterile supplies. Of course, if the wound becomes grossly infected, the client may end up in the hospital, but this response does not provide any helpful information. Good handwashing is important, but it is not the only consideration.

A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)? a. Client admitted from a nursing home with furuncles and folliculitis b. Client with a leg cut and other trauma from a motorcycle crash c. Client with a rash noticed after participating in sporting events d. Client transferred from intensive care with an elevated white blood cell count

ANS: A The client in long-term care and other communal environments is at high risk for MRSA. The presence of furuncles and folliculitis is also an indication that MRSA may be present. A client with an open wound from a motorcycle crash would have the potential to develop MRSA, but no signs are visible at present. The rash following participation in a sporting event could be caused by several different things. A client with an elevated white blood cell count has the potential for infection but should be at lower risk for MRSA than the client admitted from the communal environment.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take? a. Place the client in a single room. b. Administer an antihistamine. c. Assess the clients airway. d. Apply gloves to minimize friction.

ANS: A The clients presentation is most likely to be scabies, a contagious mite infestation. The client needs to be admitted to a single room and treated for the infestation. Secondary interventions may include medication to decrease the itching. This is not an allergic manifestation; therefore, antihistamine and airway assessments are not indicated. Gloves may decrease skin breakdown but would not address the clients infectious disorder.

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse? a. Recent wound assessment, including size and appearance b. Insurance information for billing and coding purposes c. Complete health history and physical assessment findings d. Resources available to the client for wound care supplies

ANS: A The hospital nurse should provide details about the wound, including size and appearance and any special wound needs, in a hand-off report to the home health nurse. Insurance information is important to the home health agency and manager, but this is not appropriate during this hand-off report. The nurse should report focused assessment findings instead of a complete health history and physical assessment. The home health nurse should work with the client to identify community resources.

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client? a. Punch skin biopsy b. Viral cultures c. Woods lamp examination d. Diascopy

ANS: A This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Woods lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine.

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.

ANS: A Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.

A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a. Do you have a bedpan at home? b. How are you coping with providing this care? c. What are you doing to prevent pediculosis? d. Are you sharing a bed with your husband?

ANS: B A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires moderate to maximum assistance to prevent further breakdown. Family members who care for clients at home may experience a disruption in family routines and added stress. The nurse should assess the wifes feelings and provide support for coping with changes. Asking about the clients toileting practices, prevention of pediculosis, and sleeping arrangements do not provide information about the caregivers support and coping mechanisms and ability to continue to care for her husband.

A nurse assesses a client who has psoriasis. Which action should the nurse take first? a. Don gloves and an isolation gown. b. Shake the clients hand and introduce self. c. Assess for signs and symptoms of infections. d. Ask the client if she might be pregnant.

ANS: B Clients with psoriatic lesions are often self-conscious of their skin. The nurse should first provide direct contact and touch without gloves to establish a good report with the client. Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear gloves or an isolation gown. Obtaining a health history and assessing for an infection and pregnancy should be completed after establishing a report with the client.

After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. At the next family reunion, Im going to ask my relatives if they have psoriasis. b. I have to make sure I keep my lesions covered, so I do not spread this to others. c. I expect that these patches will get smaller when I lie out in the sun. d. I should continue to use the cortisone ointment as the patches shrink and dry out.

ANS: B Psoriasis is not a contagious disorder. The client does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment should be applied directly to lesions to suppress cell division.

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Beige freckles on the backs of both hands b. Irregular blue mole with white specks on the lower leg c. Large cluster of pustules in the right axilla d. Thick, reddened papules covered by white scales

ANS: B This mole fits two of the criteria for being cancerous or precancerous: variation of color within one lesion, and an indistinct or irregular border. Melanoma is an invasive malignant disease with the potential for a fatal outcome. Freckles are a benign condition. Pustules could mean an infection, but it is more important to take care of the potentially cancerous lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales. This is a chronic disorder and is not the priority.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development? a. A 44-year-old prescribed IV antibiotics for pneumonia b. A 26-year-old who is bedridden with a fractured leg c. A 65-year-old with hemi-paralysis and incontinence d. A 78-year-old requiring assistance to ambulate with a walker

ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The client with pneumonia does not have specific risk factors. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next? a. Turn the mattress overlay to the opposite side. b. Do nothing because this is an expected occurrence. c. Apply a different pressure-relieving device. d. Reinforce the overlay with extra cushions.

ANS: C Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy? a. Do you spend a great deal of time in the sun? b. Have you or any family members ever had skin cancer? c. Which method of contraception are you using? d. Do you drink alcoholic beverages?

ANS: C Isotretinoin has many side effects. It is a known teratogen and can cause severe birth defects. A pregnancy test is required before therapy is initiated, and strict birth control measures must be used during therapy. Sun exposure, alcohol ingestion, and family history of cancer are contraindications for isotretinoin.

A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take? a. Administer it over 30 minutes using an IV pump. b. Give the client diphenhydramine (Benadryl) before the drug. c. Assess the IV site at least every 2 hours for thrombophlebitis. d. Ensure that the client has increased oral intake during therapy.

ANS: C Vancomycin is very irritating to the veins and can easily cause thrombophlebitis. This drug is given over at least 60 minutes; although it can cause histamine release (leading to red man syndrome), it is not customary to administer diphenhydramine before starting the infusion. Increasing oral intake is not specific to vancomycin therapy.

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Place the client in bed and instruct the client to elevate the foot. d. Assess the right leg for pulses, skin color, and temperature.

ANS: D A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with the assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate with his or her fingers. Tests to determine nutritional status and risk assessment would be completed after the initial assessment is done. Wound cultures are done after it has been determined that drainage, odor, and other risks for infection are present. Elevation of the foot would impair the ability of arterial blood to flow to the area.

After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching? a. Ill apply cortisone cream to reduce the inflammation. b. Ill apply a clean dressing after squeezing out the pus. c. Ill keep my arm down at my side to prevent spread. d. Ill cleanse the area prior to applying antibiotic cream.

ANS: D Cleansing and topical antibiotics can eliminate the infection. Warm compresses enhance comfort and open the lesion, allowing better penetration of the topical antibiotic. Cortisone cream reduces the inflammatory response but increases the infectious process. Squeezing the lesion may introduce infection to deeper tissues and cause cellulitis. Keeping the arm down increases moisture in the area and promotes bacterial growth.

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education? a. Use lots of moisturizer several times a day to minimize dryness. b. Take a cold shower instead of soaking in the bathtub. c. Use antimicrobial soap to avoid infection of cracked skin. d. After you bathe, put lotion on before your skin is totally dry.

ANS: D The client should bathe in warm water for at least 20 minutes and then apply lotion immediately because this will keep the moisture in the skin. Just using moisturizer will not be as helpful because the moisturizer is not what rehydrates the skin; it is the water. Bathing in warm water will rehydrate skin more effectively than a cold shower, and antimicrobial soaps are actually more drying than other kinds of soap.

The nurse is developing a teaching plan for a client diagnosed with methicillin-resistant Staphylococcus aureus infection. The nurse plans to include which instruction in the client's teaching plan? A. Take daily tub baths using a mild soap. B. Cover the infected area with a clean, dry bandage. C. Wash the infected areas first, then wash the uninfected areas. D. Use bath sponges or puffs when bathing.

B. Cover the infected area with a clean, dry bandage. The nurse includes the instruction that the infected area should be covered with a clean, dry bandage to prevent the spread of infection.The client should shower rather than take a tub bath, using an antibacterial soap. Uninfected areas should be washed first, then the infected areas should be washed, to prevent the spread of infection. Bath sponges or puffs should be avoided because they cannot be laundered. Washcloths should be used only once before laundering.

Deep tissue wounds, such as chronic pressure ulcers, take longer to heal because they heal by which intention? A. First B. Second C. Third D. Mixed

B. Second Second-intention healing is characterized by a cavitylike defect frequently found in chronic pressure ulcers. This involves gradual filling in of the dead space with connective tissue in deeper tissue injuries or wounds with tissue loss.First-intention healing is characterized in a wound without tissue loss that can be easily closed and dead space eliminated. Third-intention healing is characterized by delayed primary closure. Wounds with a high risk for infection may be intentionally left open for several days while the wound is débrided and inflammation subsides. There is no such thing as mixed-intention healing.

Which statement by a client with psoriasis indicates that teaching about the condition has been effective? A. "I know that I need to avoid warm climates." B. "I must cover up the affected areas to prevent spread to my family." C. "I should practice good handwashing technique." D. "Psoriasis can be cured with steroids."

C. "I should practice good handwashing technique." Infections such as strep throat can exacerbate psoriatic flare-ups. Therefore, handwashing is important in helping to prevent infection.Warm climates are helpful for psoriatic clients. Psoriasis is not contagious, but it cannot be cured.

A young client has been diagnosed with tinea corporis (ringworm), but the mother would like the child to return to school. To avoid spreading the infection, what does the nurse suggest to the mother? A. "Wash your hands frequently." B. "Your child may return to school, but must be isolated from the rest of the class." C. "Keep the site covered with a bandage." D. "Keep your child out of school until the infection has cleared."

C. "Keep the site covered with a bandage." "Keep the site covered with a bandage." Keeping the site covered with a bandage prevents spread of the infection.Frequent handwashing is not the best suggestion in this case. Keeping the child isolated from the other children in school or keeping the child out of school is not necessary.

During morning rounds, the nurse discovers that an older adult client has been incontinent during the night. To protect the skin, what does the nurse do first? A. Apply a barrier cream to the area. B. Assess the area for skin breakdown. C. Clean and dry the client's skin. D. Place the client in a side-lying position.

C. Clean and dry the client's skin. Cleaning and drying the client to prevent skin breakdown is the first priority for skin protection.Applying a barrier cream, assessing the area, and placing the client in a side-lying position can all be done after the client has been cleaned.

A discharged obese client will require frequent dressing changes for a skin condition on his left foot. How does the nurse assess whether the client is able to perform this task at home? A. Asks the client if he is squeamish B. Demonstrates how to change the dressing C. Determines whether the client can reach the affected area D. Provides all of the necessary dressing materials

C. Determines whether the client can reach the affected area Whether the obese client can access the dressing site is the most important thing to assess. If the dressing site cannot be accessed by the client, it will be difficult for the client to independently perform frequent dressing changes at home.The nurse would have already assessed the client's squeamishness during in-hospital dressing changes. A demonstration of how to change the dressing and providing the dressing materials are a good start, but they do not assess the client's ability to perform the task himself.

An older adult client who is bedridden has a documented history of protein deficiency. What does the nurse plan to monitor for? A. Anemia B. Decreased wound healing C. Pressure ulcer development D. Weight gain

C. Pressure ulcer development This client is at risk for developing pressure ulcers related to protein deficiency if he or she remains bedridden.Anemia and weight gain have no correlation with this client's protein deficiency. The client does not have an indicated wound.

What is the best way for the nurse to prevent a client's stage I pressure ulcer from advancing to stage II? A. Massage the reddened areas. B. Pad the ulcer. C. Promote mobility and/or frequent repositioning. D. Suggest an egg crate mattress.

C. Promote mobility and/or frequent repositioning. Frequent repositioning and/or promoting mobility is the best way to prevent further deterioration of this client's pressure ulcer.Reddened areas should never be massaged. Padding the ulcer may not be appropriate. An egg crate mattress may be suggested but is not the best option.

The nurse is caring for a client who has several infected lesions on both arms. The client is afebrile and does not have enlarged regional lymph nodes. The nurse notifies the provider who will most likely order which medication? A. Oral amoxicillin B. Oral linezolid C. Topical mupirocin D. IV vancomycin

C. Topical mupirocin Topical mupirocin is an antibiotic that is most likely to be ordered for a client with a mild bacterial skin infection without fever or lymphadenopathy.Recurrent or severe infections may be treated with oral amoxicillin. Clients with methicillin-resistant Staphylococcus aureus infections should be treated with oral linezolid or clindamycin or intravenous vancomycin if the infection is severe.

A client has had a melanoma lesion removed. For secondary prevention, what is most important for the nurse to teach the client? A. Ensure that all lesions are reviewed by a dermatologist or a surgeon. B. Avoid sun exposure. C. Have any new lesions genetically tested. D. Perform a total skin self-examination monthly with a partner.

D. Perform a total skin self-examination monthly with a partner. Perform a total skin self-examination monthly with a partner. The nurse teaches the client that performing a monthly total skin self-examination with another person is the best secondary preventive measure.If the client is taught to use the ABCDE (asymmetry, border, color, diameter, and evolving) method of lesion assessment, the client will know whether a lesion warrants assessment by a specialist. Avoiding sun exposure is primary prevention. Genetic testing of lesions is performed to determine whether targeted therapy will be effective.