Integumentary Disorders NCLEX 3000

The nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?

Post a turning schedule at the client's bedside.

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

(SELECT ALL THAT APPLY) Which nursing interventions are effective in preventing pressure ulcers?

(1) Clean the skin with warm water and a mild cleaning agent; then apply a moisturizer. (4) Turn and reposition the client every 1 to 2 hours unless contraindicated. (6) Use pillows to position the client and increase his comfort.

(SELECT ALL THAT APPLY) A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client?

(1) Reposition the client every 2 hours. (2) Perform range-of-motion exercises. (5) Encourage the client to eat a well-balanced diet.

(SELECT ALL THAT APPLY) A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis?

(1) Severe, deep pain around the thorax (2) Red, nodular skin lesions around the thorax (3) Fever (4) Malaise

(SELECT ALL THAT APPLY) A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of his body. His admission vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client?

(3) Begin an I.V. infusion of lactated Ringer's solution. (5) Administer 6 mg of morphine I.V. (6) Administer tetanus prophylaxis, as ordered.

While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

All family members will need to be treated.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft

(SELECT ALL THAT APPLY) Which instructions should be included in the teaching plan of a 19-year-old client with acne vulgaris who's prescribed tretinoin (Retin-A), benzoyl peroxide, and tetracycline (Achromycin)?

"(2) Take tetracycline on an empty stomach. (4) Maintain the prescribed treatment because it is more likely to improve acne than a strict diet and fanatic scrubbing with soap and water.

A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care?

Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session.

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.

When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

The nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates that the teaching has been effective?

I'll eat plenty of fruits and vegetables

The nurse plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest. How should the nurse apply this topical agent?

In long, even, outward, and downward strokes in the direction of hair growth

Which action should a nurse take first when admitting a client with herpes zoster infection?

Institute isolation precautions according to facility policy.

The nurse wants to help a client maintain healthy skin. Which nursing intervention will help achieve this goal?

Keeping the client well-hydrated

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide acetate (Sulfamylon)

The nurse is performing wound care. Which of the following practices violates surgical asepsis?

Pouring solution onto a sterile field cloth

The nurse is performing wound care on a client. Which task indicates surgical asepsis?

Preparing sterile surgical instruments for the physician to debride the wound

A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician prescribes tetracycline hydrochloride (Achromycin), 500 mg by mouth four times per day. Which instruction should the nurse give the client about self-administration of tetracycline?

Take the drug on an empty stomach.

An elderly client who lives at home with her daughter is admitted with unexplained bruises on her arms and legs. Which action should the nurse take first?

Assess the client thoroughly and complete the health history.

During the acute phase of a burn, the nurse should assess which of the following?

Circulatory status

Which intervention has the highest priority when providing skin care to a bedridden client?

Keeping the skin clean and dry without using harsh soaps

Which of the following nutritional deficiencies may delay wound healing?

Lack of vitamin C

A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

pain management.

The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:

protect the graft from direct sunlight.

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

cancer of the cervix.

A client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg by mouth every 4 hours while awake. The nurse should inform the client that this drug may cause:

diarrhea.

Which task can a licensed practical nurse (LPN) safely delegate to a nursing assistant?

Turning a client every 2 hours

Following a full-thickness (third-degree) burn of his left arm, a client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:

range of motion.

Despite conventional treatment, a client's psoriasis has worsened. His physician prescribes methotrexate (Trexall), 25 mg by mouth as a single weekly dose. The pharmacy dispenses 2.5 mg scored tablets. How many tablets should the nurse instruct the client to consume to achieve the prescribed dose?

10

A client with atopic dermatitis is prescribed medication for photochemotherapy. The nurse teaches the client about the importance of protecting the skin from ultraviolet light before drug administration and stresses the need to protect the eyes. After administering medication for photochemotherapy, the client must protect the eyes for:

24 hours.

A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection?

3 to 7 days

When caring for a client with severe impetigo, the nurse should expect which intervention in the plan of care?

Administering systemic antibiotics as prescribed

A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days.

A 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?

Apply sunscreen even on overcast days.

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

A client understands what resources are available to help him perform wound care at home when he states the following:

Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need.

The nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?

Behind the ears

Laboratory test results confirm that a client's wound is infected with methicillin-resistant staphylococcus aureus. Which type of isolation precautions should the nurse institute for this client?

Contact

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

Contact isolation

While assessing a client, a nurse notes a stage I pressure ulcer on the client's left hip. How should the nurse report this finding?

Document the size, extent, and location of the wound in the client's medical record

The physician 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?

Doing so prevents evaporation of water from the hydrated epidermis.

Which action by the nurse displays client advocacy during a skin assessment?

Ensuring client privacy by pulling the curtain closed

A nurse is instructing a group of nursing assistants about client care. The nurse tells them to turn clients how often to prevent skin breakdown?

Every 2 hours

A 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?

Irritation of opposing skin surfaces caused by friction

A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs?

Measure intake and output.

The nurse documents the presence of a scab on a client's deep wound. The nurse identifies this as which phase of wound healing?

Migratory

When teaching a client with intertrigo about prescribed skin care measures, the nurse should include which important instruction to prevent Candida albicans overgrowth?

Never apply cornstarch to the affected areas.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug?

Ototoxicity

The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?

Overall risk of developing pressure ulcers

A client has a foot ulcer that hasn't shown signs of improvement over the last several months. What medical condition is most likely causing the wound healing delay?

Peripheral vascular disease

Which intervention by a nurse might help prevent pressure ulcers?

Placing an alternating-current mattress on the client's bed

A nurse is instructing a client with pressure ulcers about the importance of increasing his protein intake. Why should the nurse encourage protein intake by this client?

Protein is essential for tissue repair

A client with atopic dermatitis is prescribed a potent topical corticosteroid. To address a potential client problem associated with this treatment, the nurse helps formulate the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, which "related-to" phrase should be added?

Related to percutaneous absorption of the topical corticosteroid

The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

Which of the following would the nurse expect of an elderly client's skin?

Slowed healing

Which of the following would the nurse identify as the deepest layer of the epidermis?

Stratum germinativum

Sudoriferous glands secrete which type of substance?

Sweat

The nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing?

The wound should remain moist from the dressing.

To treat a client with acne vulgaris, the physician is most likely to prescribe which topical agent for nightly application?

Tretinoin (retinoic acid [Retin-A])

After sustaining a stroke, a client is transferred to the rehabilitation unit. A medical-surgical nurse reviews the client's residual neurological deficits with a rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Urinary incontinence and right-sided hemiparesis

The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 1 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions?

Vesicles

The nurse is changing a dressing and providing wound care. Which activity should she perform first?

Wash her hands thoroughly.

A client is diagnosed with gonorrhea. When teaching the client about this disease, the nurse should include which instruction?

Wash your hands thoroughly to avoid transferring the infection to your eyes.

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client?

Wound care nurse

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:

dislodge the autografts.

When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is:

maintaining the client's fluid, electrolyte, and acid-base balance.

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:

pressurelike pain.

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:

risk manager.

A client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:

turn him frequently.

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should:

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.

The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to:

wrap elastic bandages distally to proximally on dependent areas.