Protection- Pressure ulcers, Allergies, HIV

Brian presents with a localized area of intact skin that is purple in color and warmer than adjacent tissue. The skin preceding the damaged area is firm. What do you suspect? A. Stage 1 pressure ulcer B. Stage 2 pressure ulcer C. Stage 3 pressure ulcer D. Stage 4 pressure ulcer E. Unstageable pressure ulcer F. Deep tissue injury

F.

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? a. Stage 1 pressure injury b. Deep tissue injury c. Unstageable, skin intact d. Stage 2 pressure injury

a. Stage 1 pressure injuryThis finding should be documented as a stage 1 pressure injury. The description of stage 1 pressure injury includes intact skin with nonblanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear.

A patient with a chronic diabetic wound is being discharged after receiving a skin graft to aid wound healing. What direction should the nurse include in home care instructions? A) Gently massage the graft site daily to promote perfusion. B) Protect the graft from direct sunlight and temperature extremes. C) Protect the graft site from any form of moisture for at least 12 weeks. D) Apply antibiotic ointment to the graft site and donor site daily.

ANS: B Both the donor site and the grafted area must be protected from exposure to extremes in temperature, external trauma, and sunlight because these areas are sensitive, especially to thermal injuries. Antibiotic ointments are not typically prescribed and massage may damage these fragile sites. There is no need to protect the sites from all forms of moisture for the long term.

You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers? A) Turn and reposition the patient a minimum of every 8 hours. B) Vigorously massage lotion into bony prominences. C) Post a turning schedule at the patients bedside and ensure staff adherence. D) Slide, rather than lift, the patient when turning.

ANS:C A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the patient, the nurse should lift, rather than slide, the patient to avoid shearing.

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? 1."Do you have any allergies?" 2."Will you be able to wash your own hair?" 3."Are there any areas you want us to spend more time bathing?" 4."Do you have any preferences regarding how we help you bathe?"

Answer: 1Rationale: Bed baths involve applying water and a cleans- ing agent, such as soap or chlorhexidine gluconate (CHG), to the skin. The nurse needs to first inquire about any allergies to ensure that the client is not allergic to the cleansing agent that will be used. Although options 2, 3, and 4 are appropri- ate questions to ask the client, the determination of any cli- ent allergies is the most important client data to obtain before beginning the bed bath.

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Hairdressers 2. The homeless 3. Children in day care centers 4. Individuals living in a group home

Answer: 4 Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazel- nuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross- reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy.

The nurse is caring for a patient with a pressure ulcer. Which comorbidities could the nurse expect to treat? Select all that apply. A. Anemia B. Varicose veins C. Peripheral vascular disease D. Diabetes E. Plantar fasciitis

A,C,D

The nurse is using home telehealth monitor- ing 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, the nurse should do which of the following first? 1.Instruct the home health aid to reposition the client every 2 hours while the client is awake. 2.Ask the client's daughter to purchase a foam mattress. 3.Contact the physician to request a hydrocolloid dressing. 4.Suggest that the client ask a neighbor to pur- chase antibiotic cream at the drugstore.

3. The pressure ulcer has changed from Stage I to Stage II and requires the use of a protective dressing. Repositioning and use of foam mattresses are appropriate interventions for Stage I pressure ulcers. There is no indication that the ulcer is infected.

The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should: 1.Use a fluorescent light source to assess the skin. 2.Inspect the skin only when the Braden score is above 12. 3.Look for skin color that is darker than the surrounding tissue. 4.Avoid touching the skin during inspection.

3. When assessing a client with dark skin, the nurse should observe for skin that is darker, brown- ish, purplish, or bluish compared to surrounding skin. Fluorescent light casts a blue light making skin assessment difficult; natural or halogen light sources help to accurately assess the skin. Risk assessment using the Braden Scale should be performed on all clients. A Braden score of 12 indicates a high risk for pressure ulcer and the lower the Braden score, the higher the risk (no risk 19-23, at risk 15-18, moderate risk 13-14, high risk 10-12, and very high risk 9 or below). The nurse should touch the skin to assess consistency and temperature differences.

Robert presents with full thickness tissue loss. Bone, tendon, and muscle are noted, with some slough and eschar present on parts of the wound bed. You also note undermining and tunneling. What do you suspect? A. Stage 1 pressure ulcer B. Stage 2 pressure ulcer C. Stage 3 pressure ulcer D. Stage 4 pressure ulcer E. Unstageable pressure ulcer F. Deep tissue injury

D.

Which actions should a nurse plan when caring for a client with a stage III pressure ulcer to the right lower-extremity heel? SELECT ALL THAT APPLY. 1.Monitor the client's nutritional intake 2.Assess for pain and premedicate prior to dressing changes 3.Monitor pedal pulses and capillary refill of affected extremity 4.Use hydrogen peroxide for cleaning of ulcer wound 5.Turn and reposition client every 1 to 2 hours Elevate the extremity on pillows

ANSWER: 1, 2, 3, 5, 6 Monitoring the client's nutritional intake is essential to promote wound healing. Assessing and medicating for pain, prior to dressing changes, promotes client comfort. Monitoring pedal pulses and capil- lary refill of the affected extremity alerts the nurse to further vascular compromise as a result of the wound. Repositioning the client is also important to promote circulation and to prevent further skin break- down. Elevation reduces edema, but care must be taken to avoid put- ting pressure on the ulcer. The use of hydrogen peroxide or acetic acid solutions is incorrect beca

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? a. To fill the wound with saline to dissolve wound secretions. b. To prevent the dressing from sticking to the wound. c. To promote moist wound healing and protect the wound from contamination and trauma. d. To soften the dressing to prevent trauma to the wound bed.

c. To promote moist wound healing and protect the wound from contamination and trauma. Saline-moistened dressings are used to maintain a moist wound environment to promote moist wound healing and protect the wound from contamination and trauma. A moist wound surface enhances the cellular migration necessary for tissue repair and healing. It is important that the dressing material be moist, not wet, when placed in open wounds. Although a moist dressing may also prevent sticking to the wound, this is not its primary purpose.

A nurse caring for a client is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection?(select all that apply). A. Western blot B. Indirect Immunofluorescence essay C. CD4+ T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid analysis

A and B correct C-helps classify stage, D used to determine via level and monitor tx, E-used to confirm menangitis

The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first? 1. Initiate an IV with normal saline. 2. Prepare to intubate the client. 3. Administer oxygen at 100%. 4. Ask the client about an iodine allergy.

3.The client is cyanotic with dyspnea and wheezing. The nurse should administer oxygen first.

What patients are at risk for pressure ulcers? Select all that apply. A. Patients with advanced age B. Patients with malnutrition C. Patients with insomnia D. Patients with urinary or fecal incontinence E. Patients with dehydration

A,B,D,E

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound? a. When the solution from the wound flows out clear b. When the solution from the wound flows out a pink color c. When the solution from the wound flows out a red color] d. When all the irrigation solution is finished

a. When the solution from the wound flows out clear The nurse knows to stop irrigating a wound when the solution from the wound flows out clear. The irrigation removes the exudate and debris, which turns the solution from the wound red to pink to clear, when finished. It is not necessary to use all the solution if the flow is clear already. The nurse should not stop when the return flow is red or pink, this color indicates the wound has not been thoroughly cleaned or irrigated yet.

Which client is a greatest risk of developing a pressure injury? a. 17-year-old client postoperative for fracture of the upper extremity b. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness c. 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance d. 25-year-old client on bed rest for 24 hours following a procedure

b. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness The 47-year-old client with severe alcoholism (poor nutritional status) and a traumatic brain injury (immobile) is at greatest risk for developing a pressure injury. The 17-year-old does not have any noted risk factors, the 25-year-old is young and only on bedrest for 24 hours so is very unlikely to develop a pressure injury, and the 84-year-old is ambulatory, making them a low risk for a pressure injury. For the 84-year-old client, the greatest risk is for falls.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: a. has redness with partial thickness loss of dermis. b. has bright red granulation tissue in the wound bed. c. has black brown eschar covering the top. d. has exposed bone, tendon, or muscle visible.

c. has black brown eschar covering the top. Wounds that have slough (yellow, tan, gray, green, or brown stringy tissue) or eschar covering them are considered unstageable as it is not possible to determine their depth until the slough or eschar is removed.

Which of the following is considered the best indicator of immune function in HIV-infected individuals? 1-HIV-1 viral load- 2-Presence of HIV-2 antibodies 3-CD4 T-cell count 4-Absolute lymphocyte count

3. CD4- T cell count

In educating a client about human immunodeficiency virus (HIV), the nurse should take into account the fact that the most effective method known to control the spread of HIV infection is: 1.Premarital serologic screening. 2.Prophylactic treatment of exposed people. 3.Laboratory screening of pregnant women. 4.Ongoing sex education about preventive behaviors.

4. Education to prevent behaviors that cause HIV transmission is the primary method of control- ling HIV infection. Behaviors that place people at risk for HIV infection include unprotected sexual intercourse and sharing of needles for I.V. drug injection. Educating clients about using condoms during sexual relations is a priority in controlling HIV transmission.

A nurse is caring for a client who is suspected of having HIV. The nurse should identify that which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. western blot B. indirect immunofluorescence assay C. CD 4 + T-lymphocyte count D. HIV RNA quantification test E> cerebrospinal fluid (CSF) analysis

A. western blot B. indirect immunofluorescence assay

A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will choose a diet high in fat to help gain weight." B. "I will be sure to eat three large meals daily. "C. "I will drink up to 1 liter of liquid each day." D. "I will add high-protein foods to my diet."

D. "I will add high-protein foods to my diet."

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers. 6. Use only a blood pressure cuff from an electronic device to measure the blood pressure.

1, 2, 4, 5 Rationale: Most health care facilities use latex-free products and supplies but there may be some supplies that are not available as latex-free. If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonla- tex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or mate- rials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is unnecessary to place the client in a private room.

You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. B) Patient avoids placing her body weight on the healing site. C) Patient elevates her body parts that are susceptible to edema. D) Patient demonstrates the technique for massaging the wound site.

ANS: B The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.

You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action? A) You know that this patient will have a decreased level of consciousness. B) You know that this patient may not be motivated to prevent pressure ulcers. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility.

ANS: C The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the durat

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse that the client has an understanding of the teaching? A. I will wear gloves while changing the pet litter box B. I will rinse raw fruits with water before eating them C. I will wear a mask when I am around family members who are ill D. I will cook vegetables before eating them

Ans: D

Which client would be at greatest risk for developing a pressure injury? a. Adolescent client with a cast on the left leg b. Adult client who is comatose c. Client who is delirious after taking pain medications d. Older adult client who has chronic obstructive pulmonary disease (COPD)

b. Adult client who is comatoseA client who is comatose is at greatest risk for developing a pressure injury due to the inability to turn or move in bed. This client needs to be turned regularly to prevent development of a pressure injury. The other clients have no restrictions for movement and would not be at great risk for developing a pressure injury. An older client who is bedridden (not a factor with COPD) would also be at high risk for developing a pressure injury due to age-related skin alterations.

The nurse in the emergency department is allergic to latex. Which intervention should the nurse implement regarding the use of nonsterile gloves? 1. Use only sterile, nonlatex gloves for any procedure requiring gloves. 2.Do not use gloves when starting an IV or performing a procedure. 3.Keep a pair of nonsterile, nonlatex gloves in the pocket of the uniform. 4.Wear white cotton gloves at all times to protect the hands.

3.The nurse should be prepared to care for a client at all times and should not place himself or herself at risk because the facil- ity does not keep nonlatex gloves available in the rooms. The nurse should carry the needed equipment (nonlatex gloves) with him or her.

A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors associated with the virus? (select all that apply) A. perinatal exposure B. pregnancy C. monogamous sex partner D. older adult woman E. occupational exposure

ADE

A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse that the client has an understanding of the teaching? A. I will wear gloves while changing the pet litter box B. I will rinse raw fruits with water before eating them C. I will wear a mask when I am around family members who are ill D. I will cook vegetables before eating them

D correct A, avoid, B avoid, C, avoid

A Stage II pressure ulcer is characterized by: 1. Redness in the involved area. 2. Muscle spasms in the involved area 3. Pain in the involved area. 4. Tissue necrosis in the involved area.

3. A stage II skin breakdown involves epider- mal sloughing and pain. Redness without blanching is noted in stage I. Stage III involves tissue necrosis with subcutaneous involvement. Stage IV involves muscle or bone destruction. Muscle spasms are not a criterion used in the staging process.

A client with human immunodeficiency virus (HIV) infection is taking zidovudine (AZT). The expected outcome of AZT is to: 1. Destroy the virus. 2. Enhance the body's antibody production. 3. Slow replication of the virus. 4. Neutralize toxins produced by the virus.

3. Zidovudine (AZT) interferes with replica- tion of HIV and thereby slows progression of HIV infection to acquired immunodeficiency syndrome (AIDS). There is no known cure for HIV infection. Today, clients are not treated with monotherapy but are usually on triple therapy due to a much- improved clinical response. Decreased viral loads with the drug combinations have improved the lon- gevity and quality of life in clients with HIV/AIDS. AZT does not destroy the virus, enhance the body's antibody production, or neutralize toxins produced by the virus.

Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction? 1. Administer parenteral epinephrine, an adrenergic agonist. 2. Prepare for immediate endotracheal intubation. 3. Provide a calm assurance when caring for the client. 4. Establish and maintain a patent airway

4 1. Epinephrine is the drug of choice for an anaphylactic reaction. It is a potent vasoconstrictor and bronchodilator counteracting the effects of histamine, but this is not the priority intervention. 2. This is an important intervention, but it is not the priority intervention. 3. Decreasing the client's anxiety is important, but it is not the priority intervention. 4. Establishing a patent airway is priority because facial angioedema, bronchospasm, and laryngeal edema occur with an anaphylactic reaction. Inserting a nasopharyngeal or oropharyngeal airway is the priority intervention to save the client's life.

A male client with human immunodeficiency virus (HIV) infection becomes depressed and tells the nurse: "I have nothing worth living for now." Which of the following statements would be the best response by the nurse? ■ 1. "You are a young person and have a great deal to live for." ■ 2. "You should not be too depressed; we are close to finding a cure for AIDS." ■ 3. "You are right; it is very depressing to have HIV." ■ 4. "Tell me more about how you are feeling about being HIV-positive."

4. The nurse should respond with a state- ment that allows the client to express his thoughts and feelings. After sharing feelings about their better and gives the nurse a base to respond to the client's stated fears, questions, or need for further information. Responses that make assumptions about the source of the concern or offer reinforce- ment are not supportive and block successful com- munication.

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and diarrhea. Their temperature if 38.1 degrees C (100.6 degrees F) orally. The client is concerned about the possibility of having HIV. Which of the following actions should the nurse take? (Select all that apply.) A. perform a physical assessment B. determine when manifestations began C. teach the client about HIV transmission D. draw blood for HIV testing E. obtain a sexual history

A. perform a physical assessment B. determine when manifestations began E. obtain a sexual history

Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends. Members of what group currently have the greatest risk of contracting HIV? A) Gay, bisexual, and other men who have sex with men B) Recreational drug users C) Blood transfusion recipients D) Health care providers

ANS: A Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of the population but 61% of the new infections. This exceeds the incidence among drug users, health care workers, and transfusion recipients.

You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient? A) Whole wheat macaroni with cheese B) Skim milk, oatmeal, and whole wheat toast C) Steak, baked potato, spinach and strawberry salad D) Eggs, hash browns, coffee, and an apple

ANS: C

Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion. How can the nurse best address the patients concerns? A.All the donated blood in the United States is treated with antiretroviral medications before it is used. B.That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility. C.HIV was eradicated from the US blood supply in the early 2000s. D. The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.

ANS: D The patient can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood.

A nurse notices a posting on a bulletin board for a con- tinuing education (CE) offering on the prevention of pressure ulcers. Which is the most compelling reason for the nurse to attend? 1.The unit has experienced an increase in pressure ulcers. 2.The nurse wants continuing education in order to keep up with current clinical knowledge. 3.The nurse needs one more CE unit for state license renewal. 4.The nurse is able to attend by coming in 1 hour earlier than the next scheduled shift.

ANSWER: 2 To stay current with evidence-based practice after completing a nurs- ing program, nurses must participate in ongoing education. EBP changes rapidly, and advances in health care have a strong influence on nursing practice. The other options are all reasons to attend, but the most compelling is for professional growth.

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection.

Answer: 1, 2 Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected. A list of potential allergens is identi- fied and reviewed and given to the client. For the follow-up evaluation, the size of the site has to be measured and not esti- mated. After injection, clients need to be monitored for only about 30 minutes to assess for any adverse effects.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement? 1.A fall and further injury 2.Injury to the brachial plexus nerves 3.Skin breakdown in the area of the axilla 4.Impaired range of motion while the client ambu- lates

Answer: 2 Rationale: Crutches are measured so that the tops are 2 to 3 finger widths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse clas- sify this pressure injury? 1. Stage 1 pressure injury 2. Stage 2 pressure injury 3. Stage 3 pressure injury 4. Stage 4 pressure injury

Answer: 3 Rationale: A stage 3 pressure injury is characterized by full- thickness skin loss in which adipose tissue is apparent with slough or eschar. There may also be granulation tissue and rolled wound edges. There is no exposed fascia, muscle, tendon, ligament, cartilage, or bone; this would be noted in a stage 4 pressure injury.

The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing stu- dent would indicate a need for further teaching? 1. The nursing student tells the client to avoid soak- ing the feet. 2. The nursing student dries the feet thoroughly, in- cluding in between the toes. 3. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.

Answer: 4. Rationale: Clients with diabetes mellitus are at an increased risk for impaired skin integrity related to peripheral neu- ropathy or vascular insufficiency. The feet are at an increased risk for the development of wounds and some clients may be unable to thoroughly inspect the feet regularly due to impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet would not be soaked to prevent maceration, or skin softening, as this increases the risk of infection.

You are caring for Dominic, an older patient, and are concerned about the increased potential for skin breakdown when which of the following assessment findings are noted? Select all that apply. A. Patient can turn independently B. Patient prefers bed at a 90-degree angle C. Patient has urinary incontinence D. Patient eats only 25 percent of each meal E. Patient refuses to drink any fluid between meals because of urinary incontinency

B,C,D,E

A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? A) Oral temperature of 100F B) Tachypnea and restlessness C) Frequent loose stools D) Weight loss of 1 pound since yesterday

B. In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 pound is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 100F is not considered a fever and would not be the first issue addressed.

The nurse is admitting a patient with a stage III pressure ulcer. Which serum lab values indicating inflammation and infection would the nurse expect to be drawn on the patient during the hospital stay? A. B-type natriuretic peptide and lactic acid B. Prothrombin time/International normalized ratio and partial thromboplastin time (PTT) C. C-reactive protein and erythrocyte sedimentation rate D. Hemoglobin and hematocrit

C.

The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach? The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in. The HIV virus can be eradicated from the host body with the correct medical regimen. It is difficult for the HIV virus to replicate in humans because it is a monkey virus. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.

Correct answer 1 Retroviruses never die; the virus may become dormant, only to be reactivated at a later time.

The school nurse is preparing to teach a health class to ninth graders regarding sexually transmitted diseases. Which information regarding acquired immunodeficiency syndrome (AIDS) should be included? 1.Females taking birth control pills are protected from becoming infected with HIV. 2.Protected sex is no longer an issue because there is a vaccine for the HIV virus. 3.Adolescents with a normal immune system are not at risk for developing AIDS. 4.Abstinence is the only guarantee of not becoming infected with sexually transmitted HIV.

Correct answer 4 Abstinence is the only guarantee the client will not contract a sexually transmitted disease, including AIDS. An individual who is HIV negative in a monogamous relationship with another individual who is HIV negative and committed to a monogamous relationship is the safest sexual relationship

A nurse is providing teaching for a client who has stage 2 HIV disease and is having difficulty maintaining a normal weight. Which of the following statements by the client should indicate to the nurse an understanding of the teaching ? A. I will choose a diet high in fat to help me gain weight B. I will be sure to eat three big meals a day C. I will drink up to 1 liter of liquid each day D. I will add high protein foods to my diet

D

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1′′ × 1′′ area on his sacrum in which there is skin breakdown as far as the der- mis. What should the nurse note on the chart? 1. Stage I pressure ulcer. 2. Stage II pressure ulcer. 3. Stage III pressure ulcer. 4. Stage IV pressure ulcer.

2. Stage I pressure ulcers appear as non- blanching macules that are red in color. Stage II ulcers have breakdown of the dermis. Stage III ulcers have full-thickness skin breakdown. In stage IV ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.

The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply. 1. Elevate the head of the bed to 50 degrees. 2. Obtain daily cultures 3. Cover with protective dressing 4. Reposition the client every 2 hours 5. Request an alternating-pressure mattress

3, 4, 5. The client has a Stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer cov- ered with a protective dressing.. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than30 degrees. All wounds have bacteria and obtaining frequent cultures (unless ordered otherwise) are not necessary.

Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? 1. Educate regarding drug abuse. 2. Minimize pain. 3. Maintain intact skin. 4. Increase caloric intake.

3. Maintaining intact skin is a priority forthe unconscious client. Unconscious clients needto be turned every hour to prevent complicationsof immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.

The nurse is performing a skin assessment on a cli- ent and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tis- sue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse clas- sify this pressure injury? 1. Stage 1 pressure injury 2. Stage 2 pressure injury 3. Stage 3 pressure injury 4. Stage 4 pressure injury

4. Answer: 3. Rationale: A stage 3 pressure injury is characterized by full- thickness skin loss in which adipose tissue is apparent with slough or eschar. There may also be granulation tissue and rolled wound edges. There is no exposed fascia, muscle, ten- don, ligament, cartilage, or bone; this would be noted in a stage 4 pressure injury.

The nurse would implement which nursing interventions to decrease the chance of the patient developing pressure ulcers? Select all that apply. A. Keep the draw sheet and any other bedding material located under the patient clean, dry, and without wrinkles. B. Keep the patient elevated to at least 45 degrees at all times. C. Develop and implement a turning schedule if the patient is unable to turn independently. D. Use a skin risk assessment tool such as the Braden Scale per facility policy. E. Encourage patient to sit in a chair for long periods of time.

A,C,D

Which nursing interventions address the immediate priority of care for a client experiencing a severe hypersensitivity reaction? (select all that apply) A. Assess respiratory status continuously B. Administer subcutaneous epinephrine as prescribed C. Monitor urine output D. Teach the client when and how to use an anaphylactic kit E. Administer oxygen via nasal cannula at the prescribed rate

A. Assess respiratory status continuously B. Administer subcutaneous epinephrine as prescribed E. Administer oxygen via nasal cannula at the prescribed rate

An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer? A) I B) II C) III D) IV

ANS:D Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer? 1. Partial-thickness skin loss involving the epidermis, dermis, or both 2. Full-thickness skin loss involving damage to subcutaneous tissue 3. Redness with intact skin that client reports as "itchy" 4. Full-thickness skin loss with undermining and sinus tracks

ANSWER: 2 Full-thickness skin loss involving damage to subcutaneous tissue is a description of a stage III pressure ulcer. Partial-thickness skin loss in- volving the epidermis, dermis, or both describes a stage II pressure ulcer. Redness with intact skin that a client reports as "itchy" describes a stage I pressure ulcer. Full-thickness skin loss with undermining and sinus tracks describes a stage IV pressure ulcer.

A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse emphasize during discharge education? A) Appropriate use of prophylactic antibiotics B) Importance of personal hygiene C) Signs and symptoms of wasting syndrome D) Strategies for adjusting antiretroviral dosages

Ans: B Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount. This is a more important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be independently adjusted. Prophylactic antibiotics are not normally prescribed unless the patients CD4 count is belo

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse would question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

Answer: 1 Rationale: Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surger- ies, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which nding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss with exposed dermis

Answer: 4 Rationale: In a stage 2 pressure injury, the skin is not intact. Partial-thickness skin loss with exposed dermis is present. It presents with a viable red-pink and moist wound bed. It may also present as an intact or ruptured serum-filled blister. The skin is intact in stage 1. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.

Elizabeth has been diagnosed with a stage 3 pressure ulcer on the coccyx. What nutrient would be a priority to increase in this patient's diet? A. Carbohydrates B. Protein C. Fats D. Potassium

B

A nurse in an outpatient clinic is assessing a client who reports night sweats and fatigue. The client reports having a cough along with nausea and diarrhea, Their temperature is 38.1C (100.6F)orally. The client is concerned about possibly having HIV. Which of the following actions should the nurse take? (select all that apply) A. perform a physical assessment B. determine when manifestations began C. teach client about HIV transmission D. draw blood for HIV testing E. obtain sexual history

ABE

A nurse is working with a male patient who has recently received a diagnosis of human immunodeficiency virus (HIV). When performing patient education during discharge planning, what goal should the nurse emphasize most strongly? A) Encourage the patient to exercise within his limitations. B) Encourage the patient to adhere to his therapeutic regimen. C) Appraise the patients level of nutritional awareness. D) Encourage a disease-free state,

ANS: B One of the goals of patient education is to encourage people to adhere to their therapeutic regimen. This is a very important goal because if patients do not adhere to their therapeutic regimen, they will not attain their optimal level of wellness. In this patients circumstances, this is likely a priority over exercise or nutrition, though these are important considerations. A disease-free state is not obtainable.

Which of the following nursing interventions is appropriate for preventing pressure ulcers in an older adult? 1.Clean the skin daily using mild soap and hot water. 2.Perform a systematic skin assessment at least once a day. 3.Massage bony prominences gently every shift. 4.Encourage the client to sit in a chair as much as possible.

2. Daily skin inspection is essential in pre- venting pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony promi- nences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sit- ting should be avoided; the client's position should be adjusted at least every hour.

A nurse is planning care for a 25-year-old female client who has just been diagnosed with human immunodeficiency virus (HIV) infection. The client asks the nurse, "How could this have happened?" The nurse responds to the question based on the most frequent mode of HIV transmission, which is: 1.Hugging an HIV-positive sexual partner with- out using barrier precautions. 2.Inhaling cocaine. 3.Sharing food utensils with an HIV-positive person without proper cleaning of the uten- sils. 4.Having sexual intercourse with an HIV- positive person without using a condom.

4. HIV infection is transmitted through blood and body fluids, particularly vaginal and seminal fluids. A blood transfusion is one way the disease can be contracted. Other modes of transmission are sexual intercourse with an infected partner and sharing I.V. needles with an infected person. Women diagnosis, clients will need information, support, and community resources. Statements of encourage- ment or agreement do not provide an opportunity for the client to express himself.

A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond? A) Liaise with the physical therapist to ensure that the patient is performing exercises safely. B) Validate the patients efforts to increase blood perfusion to the graft site. C) Remind the patient that ROM exercises should be passive, not active. D) Remind the patient of the need to immobilize the graft to facilitate healing.

ANS: D The nurse should instruct the patient to keep the affected part immobilized as much as possible in order to facilitate healing. Passive ROM exercises can be equally as damaging as active ROM.

The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of Acquired Immune Deficiency Syndrome (AIDS)? 1. The client's CD4 count is 189. 2. The client has an Hgb of 9.4 and Hct of 29.1. 3. The client's chest x-ray show infiltrates. 4. The client complains of a headache unrelieved by Tylenol.

1.The diagnosis of AIDS is determined by predefined criteria: A CD4 count less than 200; a fungal infection candidiasis of the bronchi, lungs, esophagus or Pneumocystis jiroveci pneumonia (PJP); disseminated extrapulmonary coccidioidomycosis; dis- seminated extrapulmonary histoplasmo- sis; a viral issue, cytomegalovirus (CMV) disease other than liver, spleen, or nodes; CMV retinitis herpes simplex virus with chronic ulcers or bronchitis, pneumonia, no guarantee the condom does not break, resulting in shared fluids. The more part- ners, the greater the risk.

Which of the following is a risk factor for the development of pressure ulcers? 1. Ambulating less than twice a day. 2. An indwelling urinary catheter. 3. Decreased serum albumin level. 4. Elevated white blood cell count.

3. Risk factors for the development of pres- sure ulcers include poor nutrition, indicated by a decreased serum albumin level. According to theGuidelines for Pressure Ulcers published by the Agency for Healthcare Research and Quality, other risk factors include immobility, incontinence, and decreased sensation. A client who does not ambu- late often can be repositioned frequently to prevent pressure ulcers. Having an indwelling urinary cath- eter does not normally increase the risk of develop- ing a pressure ulcer unless pressure from the tubing impinges on urethral or other tissue. An elevated white blood cell count does not place a client at risk for pressure ulcers

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treat- ment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing

Answer: 2 Rationale: A stage 1 pressure injury is characterized by intact skin with nonblanchable erythema. Dressings used to man- age a stage1 pressure injury include transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epidermal loss over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist environment for wound healing. Calcium alginate is absorbent and is used in stage 4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for pressure injuries that are infected.

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treat- ment of this wound? 1. Hydrogel dressing2. Transparent dressing3. Antimicrobial dressing4. Calcium alginate dressing

Answer: 2. Rationale: A stage 1 pressure injury is characterized by intact skin with nonblanchable erythema. Dressings used to man- age a stage1 pressure injury include transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epidermal loss over a period of 7 to 14 days. Hydrogel dressings are used to maintain a moist environment for wound healing. Calcium alginate is absorbent and is used in stage 4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for pressure injuries that are infected.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. a. Skin around injury is red and warm to touch b. No bone, tendon, or muscle visible. c. Drainage is foul smelling and green in color d. Visible subcutaneous fate. Full-thickness tissue loss

b. No bone, tendon, or muscle visible. d. Visible subcutaneous fat e. Full-thickness tissue loss The assessment findings which will help the nurse determine the stage of a client's pressure injury are: subcutaneous fat is visible; there is full-thickness tissue loss; and no bone, tendon, or muscle is visible in the wound bed. This information should lead the nurse to document this as a stage 3 pressure injury. The skin being red and warm to the touch and the green foul drainage are indications of wound infection, but do not influence the staging of the client's pressure injury

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? a. Remove the eschar by irrigating with sterile saline. b. Prescribe the client a high carbohydrate diet to promote healing. c. Teach the client ways to relieve the pressure on the heel. d. Teach the client to reposition every 4 hours.

c. Teach the client ways to relieve the pressure on the heel. The best nursing intervention at this time is to teach the client ways to relieve the pressure on the heel to prevent further damage. Stable eschar serves as "the body's natural (biological) cover" and is only removed by health care provider order. Teaching the client to reposition is a good intervention, but the client should be taught to reposition at least every 2 hours. The client would need adequate protein to promote healing, not carbohydrate.