PrepU Questions: Week 16--Respiratory & Skin/Wounds

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

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."

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

During a routine appointment, a young client presents a piece of hand drawn artwork to the doctor. The client has a "lump of skin" on the longest digit the right hand—the client's coloring hand. What is the pathophysiology behind this lump? Select all that apply.

-accelerated epidermal cell production -callus

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent your legs from rotating outward."

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad?

105°F to 109°F (40.5°C to 43°C)

The nurse is changing the dressing of a chronic wound. There is no sign of infection or heavy drainage. How long will the nurse leave the wound covered for?

48-72 hours

A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set?

80 to 125 mm Hg

A client has been diagnosed with shingles. Which of the following medication classifications will reduce the severity and prevent development of new lesions?

Antiviral

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?

Asthma

For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.

Diaphragm contracts and elongates the chest cavity.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign?

Fluid retention

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)?

MRI can view soft tissues and can help stage cancers.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

Upon palpation of the sinus area, what would the nurse identify as a normal finding?

No sensation during palpation

The nurse recognizes which condition is associated with emboli to the skin?

Petechiae

What is the primary function of the larynx?

Producing sound

Photochemotherapy has been used as a treatment for which of the following skin disorders?

Psoriasis

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down

Petechiae are associated with which of the following disorders?

Thrombocytopenia

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

Tretinoin (retinoic acid [Retin-A])

When assessing a patient's skin, the nurse would use palpation to assess which of the following?

Turgor

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant?

Type II cells

A health care provider orders irrigation with normal saline for the treatment of a client's wound. What should the nurse do when performing this intervention?

Use clean technique instead of sterile technique if the wound is closed.

What advice should the nurse give a client with dermatitis until the etiology of the dermatitis is identified?

Wear rubber gloves when in contact with soaps.

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of:

ataxia

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

bronchospasm

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids

The purpose of melanin is to:

determine skin color

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?

dull

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

foot drop.

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:

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

The classic lesions of impetigo manifest as

honey-yellow crusted lesions on an erythematous base.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movement

The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use?

powered full-body lift

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client?

slight Trendelenburg

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage II

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

The nurse teaches the client who demonstrates herpes zoster (shingles) that

the infection results from reactivation of the chickenpox virus.

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

the pons

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

to provide drainage for bile.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

true

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

wheezing

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form."

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.

-"Continued socialization with others is important." -"Discuss with the client switching to a portable oxygen device." -"Invite friends and family to the client's house."

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply.

-"Respirations of the client with emphysema can be compared to a balloon that has been blown up before." -"Emphysema, like a new balloon, takes less effort to empty air out of the alveoli."

Which actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

-Clean the wound from top to bottom. -Use a sterile applicator to apply any ointment that is ordered. -Use a new gauze for each wipe of the wound. -Avoid touching the wound bed, whether with gloves or forceps.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply.

-Exercise increases intestinal tone. -Exercise increases efficiency of the metabolic system. -Exercise increases blood flow to kidneys.

A nurse is educating a client on how to walk with crutches. Which teaching points are recommended guidelines for this activity? Select all that apply.

-Keep elbows close to sides. -Support body weight with hands and arms. -When climbing stairs, advance the unaffected leg past the crutches, place weight on the unaffected leg, and then advance the affected leg followed by the crutches.

The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply.

-Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. -Check that the valves and rubber flaps are functioning properly. -Monitor SaO2 with pulse oximeter.

Nursing students are reviewing information about the skin structure. The students demonstrate understanding of the material when they identify which of the following as being found in the epidermis? Select all that apply.

-Merkel cells -Langerhans cells -Melanocytes

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.

-Oxygen is dissolved. -Oxyhemoglobin circulates to the body tissue. -Adequate red blood cells are needed for oxygen transport

A nurse is teaching a client about the functions of the larynx. What should the nurse include in the teaching? Select all that apply.

-Producing sound -Facilitating coughing -Protecting the lower airway from foreign objects

A 55-year-old male client with emphysema worked with photography chemicals and smoked cigarettes for 30 years. Which symptom(s) will the nurse expects to find? Select all that apply.

-Wheezing -Chronic cough -Shortness of breath -Loss of appetite

The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply.

-When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling. -Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. -MDIs deliver a controlled dose of medications with each compression of the canister.

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

The nurse is caring for a client with chronic obstructive pulmonary disease who has been admitted to the hospital unit for pneumonia. The nurse notes that the client has a nonproductive cough and has SpO2 of 92%. Before attempting to obtain a sputum specimen, which action will the nurse take first?

Administer inhalation therapy using a nebulized mixture of oxygen and humidification.

The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?

Apply steady, firm pressure on the puncture site for 5 to 15 minutes.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial blood gas

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body?

Autograft

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 assessing a patient's nails and observes Beau's lines. Which of the following depicts this condition?

Beau's lines, (option C) are transverse depressions in the nail that may reflect retarded growth of the nail matrix because of severe illness or more commonly local trauma.

The nurse is caring for a client with a suspected skin malignancy. The nurse anticipates that the client will undergo which diagnostic test?

Biopsy

In a patient diagnosed with increased intracranial pressure (IICP), the nurse would expect to observe which of the following respiratory rate or depth?

Bradypnea

A dark-skinned firefighter is admitted to the emergency room with smoke inhalation. An assessment result indicates possible carbon monoxide poisoning. What is the indicator noted on the assessment?

Cherry red color to the nail beds, lips, and oral mucosa

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

What finding by the nurse may indicate that the client has chronic hypoxia?

Clubbing of the fingers

A client has an elevated temperature. The nurse is applying a cool compress to his forehead. This is an example of which of the following types of heat loss?

Conduction

Which is not considered a skin appendage?

Connective tissue

Which secondary skin lesions are associated with eczema?

Crusts

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin?

Dermis

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Do not eat or drink for 6 hours before the procedure.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

The nurse is differentiating between a macule and a papule when evaluating a client's skin lesion. The nurse determines that the lesion is a papule when which characteristic is noted?

Elevated and palpable

A physician wants a study of diaphragmatic motion because of suspected pathology. What does the nurse anticipate that the physician will most likely order?

Fluoroscopy

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient?

Herpes zoster

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

Which skin condition is caused by staphylococci, streptococci, or multiple bacteria?

Impetigo

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

Nursing students are reviewing information about various types of skin lesions. The students demonstrate understanding of the information when they identify which of the following as a vascular lesion?

Spider angioma

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?

Take deep breaths and cough forcefully.

The client is returning from the operating room following a bronchoscopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment?

The nursing assistant is pouring a glass of water to wet the client's mouth.

The nurse working at a physician's office is providing teaching to the parent of a child diagnosed with Tinea capitis (ringworm of the head). How often should the nurse instruct the parent to shampoo the child's hair with ketoconazole or a selenium sulfide shampoo?

Twice weekly

A client is being treated for acne vulgaris. What warning must be given to this client regarding the application of benzoyl peroxide?

Use gloves with application.

The nurse notes that the client demonstrates generalized pallor and recognizes that this finding may be indicative of

anemia

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:

apnea

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?

apply oxygen