Medical-Surgical Nursing - Integumentary Disorders

A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering I.V. fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse? Assess patency of the I.V. site every 4 hours. Carefully monitor the client for signs of fluid overload. Confirm that a large-bore catheter was inserted. Ensure a fluid volume sufficient to prevent shock.

Ensure a fluid volume sufficient to prevent shock.

A 17-year-old female with severe nodular acne is considering treatment with isotretinoin. What does the nurse instruct the client to do prior to beginning the medication? Enroll in a risk management plan. Have proof of a mental health evaluation. Begin an effective form of birth control with the first dose. Temporarily give up sports.

Enroll in a risk management plan.

A client has a foot ulcer that has not shown signs of improvement over the past several months. Which medical condition is most likely causing the delay in wound healing? Select all that apply. multiple myeloma hepatitis Parkinson's disease peripheral vascular disease diabetes

peripheral vascular disease diabetes

When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by: close adherence to a turning schedule. keeping the skin clean and dry. proper positioning and moving of the client. use of skin lubricants.

proper positioning and moving of the client.

The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures? high Fowler's semi-Fowler's prone supine

supine

Sudoriferous glands secrete which type of substance? sweat oil hormones cerumen

sweat

An older adult has several ecchymotic areas on the left arm. What should the nurse further assess? Select all that apply. elder abuse self-inflicted injury increased capillary fragility and permeability increased blood supply to the skin shingle

elder abuse self-inflicted injury increased capillary fragility and permeability

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding? "I will limit my intake of red meat to once a week." "I'll make sure that I keep the site covered at all times." "Increase in redness of the ulcer means better blood flow." "I'll eat plenty of fruits and vegetables."

"I'll eat plenty of fruits and vegetables."

A client with psoriasis is scheduled for ultraviolet B (UVB) phototherapy. Which statement by the client indicates a correct understanding of this form of treatment? "Phototherapy can slow down the production of skin cells." "This treatment may cure me of psoriasis." "I should immediately report any itching to my primary healthcare provider." "I will discontinue using any creams or lotions while receiving this therapy."

"Phototherapy can slow down the production of skin cells."

A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply. "Use pressure-reduction devices." "Increase carbohydrates in the diet." "Reposition every 1 to 2 hours." "Teach the family how to care for the wound." "Clean the area around the ulcer with mild soap." "Avoid the use of support-surface therapy."

"Reposition every 1 to 2 hours." "Teach the family how to care for the wound." "Clean the area around the ulcer with mild soap." "Use pressure-reduction devices."

A healthcare provider orders 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? "To encourage the growth of new skin cells while the skin is moist." "To prevent evaporation of water from the hydrated epidermis." "To minimize cracking of the dermis that occurs after bathing." "To prevent skin inflammation from the soaps that are used."

"To prevent evaporation of water from the hydrated epidermis."

The client presents to the emergency department (ED) after a motor vehicle accident (MVA). While the nurse is assessing the client for local inflammation, the client asks, "What are you looking for?" What is the best response by the nurse? Select all that apply. swelling bruising redness pain increased heat at the site

swelling redness pain increased heat at the site

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate? body weight body temperature urine output urine specific gravity

urine output

A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective? blood pressure greater than 120/80 mmHg oriented to person urine output at 0.5 mL/kg/hour heart rate 135 beats/minute

urine output at 0.5 mL/kg/hour

Which type of mouth care is most appropriate when the nurse is caring for a client with dentures who has severe stomatitis? using a soft toothbrush to provide oral hygiene rinsing the mouth with a commercial mouthwash before and after each meal cleansing the gums and oral mucosa with an oral swab with an astringent every shift keeping dentures in place to decrease development of edema

using a soft toothbrush to provide oral hygiene

A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply. "Use sheepskin pads in the bed and wheelchair." "Adequate intake of carbohydrates is essential for skin health." "Friction and shear increase a paralyzed client's risk of pressure ulcers." "Positioning the client at 90 degrees from the head of the bed is most therapeutic." "You need to perform range-of-motion exercises only when the client asks you to do so."

"Use sheepskin pads in the bed and wheelchair." "Friction and shear increase a paralyzed client's risk of pressure ulcers."

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first? Prepare an incident report. Prepare a disciplinary warning for the nursing assistant. Document the findings. Contact the shift supervisor.

Document the findings.

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 birth. Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days. Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms. A client with genital herpes lesions may have sexual contact but must use a condom.

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

A client with a burn on 30% total body surface area (TBSA) weighs 198 lb (90 kg). If intravenous fluids are replaced at the lowest acceptable rate, how much fluid should the client receive in the second 8 hours? Record your answer using a whole number.

The Parkland formula states that fluid should be replaced at 2-4 ml/kg. Half is to be given in the first 8 hours, a quarter in the second 8 hours, and a quarter in the last 8 hours. If the lowest acceptable amount is used, 2 mL x 90 kg x 30 TBSA = 5,400 ml should be infused over 24 hours. 2,700 mL would be given in the first 8 hours, and 1,350 mL would be given in the second and last 8 hours.

The nurse is wrapping a burned client's hand with a dressing. What is an important consideration when applying a dressing to the client's hand? Do not use an elastic wrap to hold the bandage. The hand and finger surfaces do not touch. The hand and fingers are not elevated above heart level. The bandage material is moistened with sterile normal saline solution.

The hand and finger surfaces do not touch.

Which client should receive a shingles vaccine? a client who has never had chickenpox a client who is at risk for genital herpes a client who is over 50 years of age a client who has a compromised immune system

a client who is over 50 years of age

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan? placing mitts on the client's hands administering systemic antibiotics as ordered applying topical antibiotics as ordered continuing to administer antibiotics for 21 days as ordered

administering systemic antibiotics as ordered

Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy? client with chronic obstructive pulmonary disease client with Legionella-related pneumonia client with a compromised skin graft client with an open fracture of the femur

client with a compromised skin graft

Which infections require contact precautions? Select all that apply: clostridium difficile tuberculosis methicillin-resistant staphylococcus aureus measles pertussis

clostridium difficile methicillin-resistant staphylococcus aureus

The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause palpitations. dizziness. diarrhea. a metallic taste.

diarrhea

A school-age client is experiencing severe itching in both hands that is worse at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. Which nursing diagnosis should the nurse use to plan care for this client? acute pain impaired skin integrity sleep deprivation risk for infection

impaired skin integrity

A nurse 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 wash their hands, apply a pediculicide to the client's scalp, and remove any observable mites. isolate the client's bed linens until the client is no longer infectious. notify the nurse in the day surgery unit of a potential scabies outbreak. place the client on enteric precautions.

isolate the client's bed linens until the client is no longer infectious.

In a client who has been burned, which medication should the nurse expect to use to prevent infection? gamma benzene hexachloride diazepam mafenide meperidine

mafenide The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Gamma benzene hexachloride is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.

A client seeks medical care for a first-degree burn over the chest, back, face, and arms from sun exposure. Which should the nurse identify as the primary concern? hydration infection skin cancer pain management

pain management

A client has a circular rash on their leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that the client has Lyme disease. The client's physician orders tetracycline hydrochloride , 500 mg P.O. q.i.d. Which instruction about taking tetracycline should the nurse give the client? "Take the drug on an empty stomach." "Take the drug with food or milk." "Take the drug with an antacid that contains magnesium to reduce irritability." "Take the drug with an iron supplement."

"Take the drug on an empty stomach."

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? removing eschar from the skin applying continuous-compression wraps wearing clothing to protect the burn from the sun maintaining wound care irrigation

applying continuous-compression wraps

During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? little fluctuation in daily weight hourly urine output of 60 mL serum albumin level of 3.8 g/dL (38 g/L) serum creatinine level of 2.5 mg/dL (221 µmol/L)

serum creatinine level of 2.5 mg/dL (221 µmol/L)

During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The health care provider's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply. The disorder is contagious. This is an allergic reaction. Based on the location, it is likely that detergents in the bed linens caused the rash. The skin is infected wherever the rash has developed. Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved. Washing with antibacterial soap will help the rash.

This is an allergic reaction. Based on the location, it is likely that detergents in the bed linens caused the rash. Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved.

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? The dressing should keep the wound moist. The wet-to-damp dressing should be tightly packed into the wound. The dressing should be allowed to dry out before removal. A plastic sheet-type dressing should cover the wet dressing.

The dressing should keep the wound moist.

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse? a wound measuring 9 cm × 5 cm × 0.5 cm with granulation tissue a wound measuring 1 cm × 2 cm × 0.5 cm with a red, moist wound bed a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance a wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue

a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance

The nurses teaches the parent of a child with severe burns about the importance of specific nutritional support in burn management. The nurse recognizes the need for more teaching if the parents select which food for their child? bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie chicken nuggets, orange and grapefruit sections, and a vanilla milkshake beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk

bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks

The nurse is assessing a client who experienced second- and third-degree burns of the arms and hands from a kitchen grease fire. After determining that the client did not experience an inhalation injury, which assessment should be completed next? pain assessment orientation extensiveness and depth of the burns blood pressure and heart rate

blood pressure and heart rate

A male client with hair on the chest is prescribed dexamethasone cream for a rash over the midthoracic region. Which approach should the nurse use to apply this topical medication? with a circular motion, to enhance absorption with an upward motion, to increase blood supply to the affected area in long, even, outward, and downward strokes in the direction of hair growth in long, even, outward, and upward strokes in the direction opposite hair growth

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

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. Over the past few weeks, the client has been spending less time in the wheelchair. During the appointment, the nurse notes that the client is not using a cushion and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen? Ask the client to explain the treatment regimen. Call the family contact to ask about how the treatments have been done. Explain pressure ulcer development in terms that the client understands. Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

Ask the client to explain the treatment regimen.

During initial rounds, a nurse notes that a norepinephrine infusion has extravasated into the forearm of a client. After stopping the infusion, the nurse follows standing orders and prepares to administer phentolamine. Which action by the nurse is appropriate when administering this drug? Inject subcutaneously in a circular fashion around the extravasation site. Massage topically in a circular fashion around the extravasation site. Dilute in saline and administer intravenously. Mix the oral form with soda or juice and have the client drink through a straw.

Inject subcutaneously in a circular fashion around the extravasation site. For treatment of dermal necrosis and sloughing following intravenous administration or extravasation of norepinephrine, administer 5 to 10 mg of phentolamine mesylate in 10 mL of saline subcutaneously in a circular fashion around the extravasation site within 12 hours. None of the other administration techniques are correct, massage will worsen the extravasation, and the medication should not be administered orally.