NCLEX 10000 INTEGUMENTARY

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:

proper positioning and moving of the client.

When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch?

roast beef sandwich, milkshake, and cottage cheese

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?

stage II pressure ulcer

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first:

verify the prescription to use the restraint.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:

wrap elastic bandages distally to proximally on dependent areas

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?

Administer pain medication 30 minutes before therapy to help manage pain.

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate?

Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure.

A nurse is performing a skin assessment on a younger adult. Which of the following skin changes should the nurse observe in this client?

Asymmetry, border irregularity, color variation, and diameter

The emergency nurse is performing an assessment on a client who experienced second and third degree burns of the arms and hands from a kitchen grease fire. Which assessment should be performed first?

Blood pressure and heart rate

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

Develop a written, individual turning schedule.

At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis?

Fear related to potential diagnosis of malignant melanoma.

A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first?

Formally report her concerns to the nurse-manager.

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

Hoarseness of the voice

A nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do?

Instruct the client to elevate the left leg when sitting in the chair.

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

Keeping the skin clean and dry without using harsh soaps

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?

Irrigate the wounds with water.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?

Lactated Ringer's solution

A client reports a firm, red nodule with a scaly crust on his back. Which of the following is the best nursing intervention?

Notify the healthcare provider.

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should assess the client for which adverse reaction?

Ototoxicity

A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused, with reports of minor pain. When assessing the client, which of the following is an immediate priority for the nurse to evaluate?

Patency of airway

"I will take the antibiotics until the redness goes away and my foot feels better."

Replace lost fluids.

Sudoriferous glands secrete which type of substance?

Sweat

A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception?

Tattoos are easily removed with laser surgery.

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

Tretinoin

A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?

Turn him regularly.

A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 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

At about one-half hour before the daily whirlpool bath and dressing change the nurse should:

administer an analgesic.

A nurse visits the employee health department because of mild itching and a rash on both hands. During the assessment interview, the employee health nurse should focus on:

chemical and latex glove use.

The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:

ensure adequate caloric and protein intake.

After the initial phase of the burn injury, the client's plan of care will focus primarily on:

preventing infection.

A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to:

reposition the client off the reddened skin and reassess in a few hours.

A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say?

"I'm sorry, but I can't share confidential information."

The nurse is assessing a client with dark skin for presence of a stage I pressure ulcer. The nurse should:

look for skin color that is darker than the surrounding tissue.

The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions, which areas have provided effective outcomes in preventing pressure ulcers? Select all that apply.

Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. Turn and reposition the client every 1 to 2 hours unless contraindicated. Use positioning devices to position the client and increase comfort.

Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy?

a compromised skin graft.

A client visits the physician's office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to order:

a topical agent.

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

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

A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms."

A physician 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 prevent evaporation of water from the hydrated epidermis."

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." "Friction and shear increase a paralyzed client's risk of pressure ulcers."

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 received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned.

45%

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 2 cm × 2 cm × 0.5 cm with tan leathery appearan

What important assessment data will help the nurse ensure accurate fluid replacement for a client with burns?

Age, weight, vital signs, and tissue turgor

A client who is bound to a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair, he uses a cushion. During his appointment the nurse notes that he 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 his treatment regimen?

Ask the client to explain his treatment regimen.

The nurse is caring for a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which information would be included in a teaching plan that focuses on home care? Select all that apply.

Avoid exposure to sunlight. Keep exercise to a minimal level. Avoid over-the-counter (OTC) medications unless approved by the physician. Take rest periods as needed.

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

The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do first?

Contact the health care practitioner (HCP) to request a hydrocolloid dressing.

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to do which of the following? Select all that apply.

Document the condition of the client's skin. Turn the client when in bed.

A teenager is admitted to the burn unit with third-degree burn injuries over more than 40% of the body. When administering IV fluids to the client within the first 48 hours of injury, what is the most important responsibility of the nurse?

Ensure a fluid volume sufficient to prevent shock.

A nurse plans to apply dexamethasone cream to a client's 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

A client presents to the emergency department with a foot lesion. When documenting the foot lesion in the medical record, which medical terms would a nurse use to classify the pictured lesion found below? Select all that apply.

Linear Fissure

The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed.

Which action should the nurse take to provide the most effective emergency care at the accident site for a victim with a heat burn?

Pour cool water over the burned area.

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

Scale

The nurse is reading the progress notes for a client who has a pressure ulcer. Based on the nurse's note in the chart, what stage pressure ulcer does this client have?

Stage II

A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

The client's complete blood count readings reflect a reduced hematocrit.

An older adult has several ecchymotic areas on the left arm. The nurse should further assess the client for: (Select all that apply.)

elder abuse. self-inflicted injury. increased capillary fragility and permeability.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention.

The nurse is caring for a client who has deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, there will be a fluid shift from the:

intravascular to the interstitial compartment.

Which client should receive a shingles vaccine? A client who:

is older than 60 years.

A nurse is planning an educational program about cancer prevention and detection. Which group would benefit most from education regarding potential risk factors for melanoma?

parents with children

A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when the nurse applies pressure and observes for color change when pressure is released and the skin color changes to:

reddish.

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

"All family members need to be treated."

A female 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 best prevents skin damage?

"Apply sunscreen even on overcast days."

A client presents at the health care provider's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? Select all that apply.

Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. Severe itching of the affected areas, especially at night, is a common finding. All of the client's linens and clothing should immediately be washed in hot water.

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect?

Scabies

The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client isn't reporting of more pain. Which of the following is the best response by the nurse?

"The severe burns have damaged nerves that sense pain."

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias.

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.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for:

IV rate increase

The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following?

Impaired skin integrity

A well-nourished client is admitted with a stasis ulcer. The nurse assesses the ulcer and finds excavation of the skin surface as a result of sloughing of inflammatory necrotic tissue. The health care provider (HCP) has prescribed the ulcer to be flushed with a fibrinolytic agent. Which goals are appropriate for this client? Select all that apply.

Increase oxygen to the tissues. Prevent direct trauma to the ulcer. Prevent infection. Reduce pain.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's daughter asks if the hospital can "treat the sore." What is the best initial response the nurse should state?

We will collaborate with the physician to obtain an order for the wound care nurse to see the client."

The nurse is assessing a client with a burn injury using the "rule of nines" to determine:

amount of body surface area burned.

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

amount of subcutaneous tissue

A child has been prescribed diphenhydramine hydrochloride to help control the itching from atopic dermatitis. The nurse should instruct the parents to report which conditions? Select all that apply.

drowsiness thickened bronchial secretions upset stomach

While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for:

gastrointestinal ulceration.

A nurse is teaching a client about skin cancer. Which risk factors for skin cancer should the nurse explain? Select all that apply.

increasing age exposure to chemical pollutants long-term exposure to the sun genetics immunosuppression

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?

intravenous opioids

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?

mobility status

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 suggests necrotizing fasciitis is:

pressurelike pain.

A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:

some melanomas have a familial component and she should seek medical advice.

Which client is at greatest risk for inadequate nutrition?

the client with burns to 45% of the body

When bandaging the burned client's hand, the nurse should make certain that

the hand and finger surfaces do not touch.

The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot. The client originally scraped the foot on a rock while walking barefoot outside; the scrape became infected and eventually required hospitalization for wound care and several days of IV antibiotics. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse?

"I will take the antibiotics until the redness goes away and my foot feels better."

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 40 ml/hour (40 mL/hour)

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply.

Add baking soda to the water in a tub bath. Keep nails short and clean. Rub the skin when it itches with knuckles instead of nails.

A client who is taking acetylsalicylic acid (ASA) caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which action first?

Apply an ice pack for 20 minutes.

The nurse has positioned the client on the right side (see figure). Which areas will the nurse assess for pressure when repositioning two hours later. Select all that apply.

Auricle Clavicle Ankle Greater trochanter

The nurse is caring for an immune compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?

Avoid sharing combs and brushes.

A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that his children work and no one has time to assist him with his self-care activities. The nurse should:

Contact the nursing supervis

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

Mafenide

A night-shift nurse receives a call from the emergency department about a client with herpes zoster who is going to be admitted to the floor. Based on this diagnosis, where should the nurse assign the client?

Private room

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

The nurse is developing a program on skin cancer prevention for a community group. Which information should be included in the program? Select all that apply.

Purchase sunscreen containing benzophenones to block UVA and UVB rays. Use sunscreen with a minimum of 30 sun protection factor (SPF).

A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply.

Severe, deep pain around the thorax Red, nodular skin lesions around the thorax Fever Malaise

What should the nurse instruct the client with tinea capitis to do? Select all that apply.

Shampoo hair two or three times with selenium sulfide shampoo. Take antifungal medication as prescribed.

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

Small, waxy nodule with pearly borders

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer

Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment, the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist (ET). When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate? Select all that apply.

The ulcer is superficial, like a blister. Partial-thickness skin loss of the epidermis is evident.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

dislodge the autografts.

A nurse is caring for an older adult with shingles. The client is experiencing considerable pain related to open blisters on the client's abdomen and back. The client is taking acyclovir and low dose prednisone. The nurse has several prescriptions available. What additional medications or nursing care strategies to promote comfort may be helpful? Select all that apply.

diphenhydramine 25 mg by mouth every 6 hours PRN calamine lotion applied to the affected areas cool, wet compresses to the affected areas acetaminophen 325 mg by mouth every 6 hours PRN diversionary activities to prevent client scratching

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?

urine output

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?

urine output of 30 mL/h

Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts?

use of analgesics as necessary for pain relief

A 17-year-old female with severe nodular acne is considering treatment with isotretinoin. Prior to beginning the medication, the nurse explains that the client will be required to:

enroll in a risk management plan.

Which action would be most helpful in preventing pressure ulcer formation in an at-risk client?

repositioning every hour

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy?

Maintaining the client's fluid and electrolyte balance

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?

supine

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply.

the victim with chemical spills on both arms the victim with third-degree burns of both legs the victim in respiratory distress the victim who inhaled smoke

Which clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has:

thermal burns to the head, face, and airway resulting in hypoxia.

A 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

The nurse is aware that, in addition to the rule of nines, which is the most important assessment priority when assessing a client with facial burns?

Checking for airway patency

A 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.

The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply.

Cover with protective dressing. Reposition the client every 2 hours. Request an alternating-pressure mattress.

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

Incontinence and right-sided hemiparesis

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Nutrition support and orthotics

Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:

altered protective pressure sensation.

A client is being treated for severe pediculosis. The nurse should instruct the client to treat the problem in the eyebrows and eyelashes by:

applying petroleum jelly to lashes and brows three to four times a day.

After teaching the parent of a child with severe burns about the importance of specific nutritional support in burn management, which selection of foods, if chosen by the parent from the child's diet menu, indicate the need for further instruction?

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

A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:

call the health care provider (HCP) to report the loss of the radial pulse.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

chicken and orange slices

When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer?

exposure to moisture

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?

To prevent signs of hypovolemic shock and restore circulation

The nurse is bathing a client and discovers a pressure ulcer on the buttocks (see photo). Which nursing intervention, following completion of the bath, is completed first?

Position the client off of the ulcer.

A client with atopic dermatitis is ordered 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?

Related to percutaneous absorption of the topical corticosteroid

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids.

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? Select all that apply.

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

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?

Ring or donut

When planning for risk management for clients who are at risk for development of pressure ulcers, the nurse should first:

identify at-risk clients on admission to the health care facility

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects

melanoma.

The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. The nurse should:

notify the health care provider immediately.

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?

Apply direct pressure to the finger with a clean, dry cloth.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status?

The RN communicates daily with the LPN about the condition of each resident.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which of the following statements by the nurse are correct about this type of burn? Select all that apply.

This is a severe burn and nerve endings have been destroyed. The child must be monitored for signs of fluid shift. Rehabilitation and skin grafting will be necessary.

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction should the nurse include in her teaching plan?

Use a topical skin moisturizer daily.

The registered nurse (RN) is referred to a client's home when a husband and wife have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority?

Use hot water throughout wash cycle.

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:

diarrhea.

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 him. He tells the nurse, "The nursing assistant on the last shift was rough. I asked her to look at my backside, but she told me she was too busy." What should the nurse do first?

Document her findings.