Saunders NCLEX-RN
A home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse determines the effectiveness of the medication by noting a decrease in which problem? 1.Pain 2.Rash 3.Fever 4.Sneezing
2. Rash Rationale: Clotrimazole is a topical antifungal agent used in the treatment of cutaneous fungal infections. It is not used for pain, fever, or sneezing.
The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? 1.Pallor 2.Cyanosis 3.Jaundice 4.Erythema
4.Erythema Cellulitis presents with erythema (redness), which is localized inflammation. Options 1, 2, and 3 are not signs or symptoms of cellulitis.
The nurse suspects herpes zoster (shingles) when which assessment finding is noted? 1.Clustered skin vesicles 2.A generalized body rash 3.Small blue-white spots with a red base 4.A fiery red, edematous rash on the cheeks
1.Clustered skin vesicles The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because the lesions follow nerve pathways, they do not cross the midline of the body. Options 2, 3, and 4 are incorrect descriptions of herpes zoster.
In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? 1.Fatigue 2.Constipation 3.Impaired safety 4.Altered body image
Altered body image Psoriasis is an autoimmune dermatitis that is expressed as silvery scales on reddish-colored skin on areas such as scalp, elbows, hands, and knees. Onset of the disease generally occurs before age 40, with symptoms varying in intensity from mild to severe. Skin disorders, particularly when experienced by young persons and particularly when visible on exposed body parts, can cause significant psychosocial distress. Altered body image is a priority client problem that should be considered when planning care for a client with psoriasis. The remaining options are not priority client problems associated with psoriasis.
Sodium hypochlorite is prescribed for a client with a leg wound that is draining purulent material. The home health nurse teaches a family member how to perform wound treatments. Which statement, if made by the family member, indicates a need for further teaching? 1."A fresh solution needs to be prepared frequently." 2."I should rinse the solution off immediately after the irrigation." 3."The solution should not come in contact with normal skin tissue." 4."I will soak a sterile dressing with solution and pack it into the wound."
"I will soak a sterile dressing with solution and pack it into the wound." Rationale: Sodium hypochlorite is a solution used for irrigating and cleaning necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. The solution loses its potency during storage, so fresh solution should be prepared frequently. The solution should not come into contact with healing or normal tissue and should be rinsed off immediately after irrigation.
Lindane is prescribed. The nurse reviews the client's record, knowing that this medication therapy would be contraindicated in which client? 1.A child 2.A young adult 3.An older client 4.A middle-aged client
1.A child
Which clients can safely receive lindane? Select all that apply. 1.An 89-year-old client with dementia 2.A 32-year-old client with renal stones 3.A 6-year-old child with a fractured arm 4.A 42-year-old woman with osteoporosis 5.A 52-year-old man with hypertension and high cholesterol
1.An 89-year-old client with dementia 2.A 32-year-old client with renal stones 4.A 42-year-old woman with osteoporosis 5.A 52-year-old man with hypertension and high cholesterol
The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. 1.Antibiotic therapy 2.Cold compresses to the affected area 3.Warm compresses to the affected area 4.Intermittent heat lamp treatments 4 times daily 5.Alternating hot and cold compresses continuously
1.Antibiotic therapy 3.Warm compresses to the affected area Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.
The nurse expects to note which prescription for a client with a skin infection that extends into the dermis? 1.Applying warm compresses to the affected area 2.Placing iced compresses to the affected area every 4 hours 3.Alternating the application of hot and iced compresses every 2 hours 4.Placing antibiotic ointment on the affected site followed by continuous heat lamp application
1.Applying warm compresses to the affected area Warm compresses may be prescribed to decrease the discomfort, erythema, and edema associated with a skin infection that is characteristic of cellulitis. The nurse should also provide supportive care as prescribed to manage associated symptoms such as fever or chills. After tissue and blood are obtained for culture, antibiotics are initiated. Heat lamps can cause more disruption to already inflamed tissue. Iced compresses are not prescribed because they can damage tissue.
An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. 1.Heels 2.Ankles 3.Elbows 4.Sacrum 5.Back of the head 6.Greater trochanter
1.Heels 3.Elbows 4.Sacrum 5.Back of the head When the client is lying supine, the heels, sacrum, and back of the head are all at risk, as are the elbows and scapulae. The greater trochanter and ankles are at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position.
Sodium hypochlorite solution is prescribed for a client with a wound on the left foot that is draining purulent material. Which action should the nurse plan to take? 1.Irrigate the wound with the solution. 2.Soak the foot in the solution for 20 minutes daily. 3.Place the solution in the wound, and cover with an occlusive dressing. 4.Soak a sterile dressing with the solution, and pack the dressing into the wound.
1.Irrigate the wound with the solution. Rationale: Sodium hypochlorite is a solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds but cannot be used to pack purulent wounds because the solution is inactivated by copious pus. It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation.
The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? 1.It is caused by a tick bite. 2.It can be contagious by skin contact with an infected person. 3.It can be caused by the inhalation of spores from bird droppings. 4.It is caused by contamination from cat feces or the consumption of rare or raw meat.
1.It is caused by a tick bite. Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from 1 person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the inhalation of cysts from contaminated cat feces or the consumption of rare or raw meat.
A client with severe psoriasis has a problem of chronic low self-esteem. The nurse should incorporate which nursing action when working with this client? 1.Listening attentively 2.Keeping communications brief 3.Approaching the client in a formal manner 4.Avoiding looking at the affected skin areas
1.Listening attentively Clients with chronic skin disorders may experience chronic low self-esteem because of the disorder itself and possible rejection by others. The nurse demonstrates acceptance of the client by using a quiet, unhurried manner and by using appropriate visual contact, facial expression, and therapeutic touch. Communications that seem brief and formal may reinforce the feelings of rejection, as may avoidance of looking at the affected skin areas.
The registered nurse (RN) directs the licensed practical nurse (LPN) to assist with the care of a client who has a sacral ulcer. Which is the most appropriate activity for the RN to delegate to the LPN? 1.Place the client in a side-lying position. 2.Initiate wound care protocol for standardized ulcer care. 3.Meet with the wound specialist to identify measures to improve healing. 4.Determine which treatments would best meet the healing needs of the client.
1.Place the client in a side-lying position. Rationale: The client with a diabetic ulcer needs to take strict precautions and implement very specific measures to allow for wound healing. Interventions include washing the feet with warm (not hot) water daily with a mild soap, using lanolin to prevent drying and cracking, wearing closed-toed shoes that are well fitting and avoiding high-heel and open-toed shoes, and exercising the feet daily by walking and flexing at the ankle to promote circulation.
A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse should implement which action while using this solution? 1.Rinse off immediately following irrigation. 2.Pour onto sterile sponges, and pack in wound. 3.Let the solution run freely over normal skin tissue. 4.Use each bottle of solution for 2 weeks before replacing.
1.Rinse off immediately following irrigation. Rationale: Sodium hypochlorite is a solution that is used for irrigating and cleaning necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. (It can be used to pack necrotic wounds, however.) It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. The solution is unstable, and it is best to prepare a fresh solution for use during each dressing change.
Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1.Tinnitus 2.Diarrhea 3.Constipation 4.Decreased respirations
1.Tinnitus Rationale: Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.
Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. 1.A 32-year-old African American 2.A woman experiencing menopause 3.A client with a family history of the disorder 4.An individual who has experienced a significant amount of emotional distress 5.A female client with a thin body frame who adheres to a regular exercise program
2. A woman experiencing menopause 3.A client with a family history of the disorder 4.An individual who has experienced a significant amount of emotional distress Rationale: Psoriasis is a chronic, noninfectious skin inflammation involving keratin synthesis that results in psoriatic patches. Various forms exist, with psoriasis vulgaris being the most common type. Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder also may be exacerbated by the use of certain medications. Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races and ethnic groups.
The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? Refer to figure. 1.Document the findings. 2.Apply a sterile nonadherent dressing. 3.Redress the wound with a dry sterile dressing. 4.Ask the client to cough to assess for protrusion of the internal structures.
2.Apply a sterile nonadherent dressing. Rationale: Wound dehiscence is partial or complete separation of the outer layers of the wound, sometimes described as splitting open of the wound. If this is noted, the nurse applies a sterile nonadherent dressing, such as a Telfa dressing or a saline dressing, to the wound and notifies the surgeon. The nurse would document the findings, but this would not be the initial action. A dry dressing could disrupt the integrity of the underlying tissues. Asking the client to cough could cause an extension of the separation of the outer layers of the wound.
A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? 1.Change the hydrocolloid dressing daily. 2.Change the hydrocolloid dressing every 3 to 5 days. 3.Apply the hydrocolloid dressing over a dry, sterile dressing. 4.Apply the hydrocolloid dressing over a normal saline-soaked dressing.
2.Change the hydrocolloid dressing every 3 to 5 days. Rationale: A hydrocolloid dressing contains hydroactive particles embedded in a polymer base that are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and should be changed every 3 to 5 days (or more frequently if drainage from the wound is excessive). It is not applied over a dry, sterile dressing or a normal saline-soaked dressing because it then would not be able to act as a protective gel.
The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? 1.Pillow 2.Foam pad 3.Folded blankets 4.Plastic-lined absorbent pad
2.Foam pad Rationale: The client who cannot shift weight unassisted should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the client's weight on the pad. These include foam, water, gel, and alternating air products. A pillow provides cushion but does not distribute weight equally. A plastic-lined pad and folded blankets provide no pressure relief.
The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? 1.Monitor temperature every 4 hours. 2.Leave the dressing intact for 3 to 5 days. 3.Apply an ice pack to the site to decrease edema formation. 4.Maintain the right lower extremity in a dependent position.
2.Leave the dressing intact for 3 to 5 days. After surgery, graft sites are immobilized with bulky cotton pressure dressing for 3 to 5 days to allow vascularization, or "take," of the newly grafted skin. Dressings should not be disturbed. Elevation and complete rest of the grafted area is required to allow blood vessels to connect the graft with the wound bed. Any activity that might cause movement of the dressing against the body and separation of the graft from the wound is prohibited, such as application of an ice pack. Additionally, cold promotes vasoconstriction.
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1.Milk 2.Oranges 3.Bananas 4.Chicken
2.Oranges Rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1.Red, hard skin 2.Serous drainage 3.Purulent drainage 4.Warm, tender skin
2.Serous drainage Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
A client is admitted to the hospital with a partial-thickness skin loss and blister on the sacrum. The nurse should develop a plan of care for which stage of pressure ulcer? Refer to figure. 1.Stage I ulcer 2.Stage II ulcer 3.Stage III ulcer 4.Stage IV ulcer
2.Stage II ulcer Rationale: A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact skin. Stage III ulcers are full-thickness lesions of the skin. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue.
Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1.Potassium level 2.Triglyceride level 3.Hemoglobin A1C 4.Total cholesterol level
2.Triglyceride level Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin A1C, or total cholesterol levels.
The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply. 1.Wash feet with hot water daily. 2.Use a mild soap when washing the feet. 3.Use lanolin on the feet to prevent dryness. 4.Wear open-toed shoes to allow air flow to the feet. 5.Exercise the feet daily by walking and flexing at the ankle.
2.Use a mild soap when washing the feet. 3.Use lanolin on the feet to prevent dryness. 5.Exercise the feet daily by walking and flexing at the ankle.
A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1."Come to the emergency department." 2."Apply calamine lotion immediately to the exposed skin areas." 3."Take a shower immediately, lathering and rinsing several times." 4."It is not necessary to do anything if you cannot see anything on your skin."
3. "Take a shower immediately, and lather and rinse several times." When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.
A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1."Come to the emergency department." 2."Apply calamine lotion immediately to the exposed skin areas." 3."Take a shower immediately, lathering and rinsing several times." 4."It is not necessary to do anything if you cannot see anything on your skin."
3."Take a shower immediately, lathering and rinsing several times." Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.
A hospitalized client is diagnosed with scabies. The health care provider (HCP) recommended that the client and the client's roommate be treated with lindane. Which finding, if noted on this client's chart, would alert the nurse to notify the HCP before the treatment with lindane? 1.Client history of diabetes 2.Client history of hypertension 3.Client history of seizure disorders 4.Client history of coronary artery disease
3.Client history of seizure disorders
The nurse is providing skin care instructions to a female client with acne vulgaris. What should the nurse instruct the client to do? 1.Use oil-based cosmetics. 2.Vigorously rub her face when washing it. 3.Remove cosmetics from her face at bedtime. 4.Wash her face once daily with an astringent cleanser.
3.Remove cosmetics from her face at bedtime. The client should be instructed to wash her face 2 or 3 times daily with a mild cleanser. Vigorous rubbing of the face is avoided, and cosmetics need to be removed from the face at bedtime. The client is instructed to use only water-based cosmetics and to avoid exposure to skin products that contain oils because products that are oily may cause skin flare-ups.
An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? 1.Purpura 2.Venous star 3.Spider angioma 4.Cherry angioma
3.Spider angioma Spider angiomas have a bright red center with legs that radiate outward. Spider angiomas are commonly seen in liver disease and vitamin B deficiency, although they occasionally can occur without underlying pathology. Purpura results from hemorrhage into the skin. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright red lesion on the trunk or extremities.
Isotretinoin has been prescribed for an adolescent with a diagnosis of severe cystic acne. The nurse provides instructions to the adolescent regarding the use of the medication. Which statement, if made by the adolescent, indicates a need for further instruction? 1."I will return to the clinic for blood tests." 2."My eyes may become dry and burn as a result of the medication." 3."If my lips begin to burn, this is probably because of the medication." 4."I need to be sure to take my vitamin A supplement so that the treatment will work."
4."I need to be sure to take my vitamin A supplement so that the treatment will work." Rationale: Isotretinoin is used to inhibit inflammation in the client with severe cystic acne. Vitamin A supplements are stopped during this treatment because isotretinoin is a derivative of vitamin A, and taking vitamin A concurrently will induce additive effects. Adverse effects include elevated triglycerides, skin dryness, and eye discomfort, such as dryness and burning. Lip inflammation, called cheilitis, also can occur.
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? 1."It is an acute superficial infection." 2."It is an inflammation of the epidermis." 3."Staphylococcus is the cause of this epidermal infection." 4."This skin infection involves the deep dermis and subcutaneous fat."
4."This skin infection involves the deep dermis and subcutaneous fat." Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders and spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Options 1, 2, and 3 are incorrect descriptions.
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1.A pink, edematous hand 2.Fiery red skin with edema in the nail beds 3.Black fingertips surrounded by an erythematous rash 4.A white color to the skin, which is insensitive to touch
4.A white color to the skin, which is insensitive to touch Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.
A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? 1.Purpura 2.Petechiae 3.Erythema 4.Ecchymosis
4.Ecchymosis Ecchymosis is a type of purpuric lesion, also known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin.
An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? 1.Heels 2.Sacrum 3.Back of the head 4.Greater trochanter
4.Greater trochanter Rationale: The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as are the elbows and scapulae.
A client is seen in the clinic for complaints of skin itchiness that has persisted for several weeks. After an assessment, the client is determined to have scabies. Lindane is prescribed, and the nurse provides instructions to the client regarding the use of the medication. Which action should the nurse tell the client to take? 1.Apply the cream for 2 days in a row. 2.Apply a thick layer of cream to the entire body. 3.Apply the cream to the entire body and scalp, excluding the face. 4.Leave the cream on for 8 to 12 hours, and then remove it by washing.
4.Leave the cream on for 8 to 12 hours, and then remove it by washing. Rationale: Lindane is applied in a thin layer to the body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. In most cases, only 1 application is required.
An outbreak of head lice infestation has occurred at a local school. The school nurse is providing instructions to the mothers of the children attending the school regarding the application of malathion. The nurse should tell the mothers to take which action? 1.Apply the lotion immediately after washing the hair. 2.Pour the lotion onto the hair and then rinse immediately. 3.Allow the lotion to remain on the hair for 10 minutes and then rinse with water. 4.Leave the lotion on for 8 to 12 hours, and then wash the hair with nonmedicated shampoo.
4.Leave the lotion on for 8 to 12 hours, and then wash the hair with nonmedicated shampoo. Rationale: The instructions for the use of malathion are as follows: Sprinkle lotion on dry hair and rub gently until the scalp is moistened; allow to dry naturally; after 8 to 12 hours, wash the hair with a nonmedicated shampoo; rinse and use a fine-toothed comb to remove lice; and repeat in 7 to 9 days if needed.
The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? 1.Cleans the wound with a sterile normal saline solution 2.Tapes gauze dressing in place over ulcer 3.Applies the enzymatic agent to the area of necrosis 4.Leaves the ulcer open to the air after the enzymatic agent is applied
4.Leaves the ulcer open to the air after the enzymatic agent is applied Rationale: The wound should be cleansed with a sterile solution, such as normal saline, before applying the enzymatic agent. The nurse then applies a thin film of the enzymatic agent on the necrotic areas only and applies a loose, thin dressing taped securely in place.
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 II pressure injury in the sacral area. Which finding 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 of the dermis
4.Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.
The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? 1.Rapid and continuous rewarming of the toes after flushing returns 2.Rapid and continuous rewarming of the toes in cold water for 45 minutes 3.Rapid and continuous rewarming of the toes in hot water for 15 to 20 minutes 4.Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs
4.Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs Acute frostbite is treated ideally with rapid and continuous rewarming of the tissue in a warm water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because they can contribute to increased cellular damage. Cold or hot water is not used. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.
A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? 1.Dry sterile dressing 2.Wet to dry dressing 3.Gelfoam sponge dressing 4.Semipermeable film dressing
4.Semipermeable film dressing Semipermeable film dressings are used on superficial wounds, on ulcers, and occasionally on some deep, draining, or necrotic ulcers. These dressings have the advantage of staying in place for several days, allowing tissues to heal underneath. Dry sterile dressings would stick to the wound and are inappropriate. Wet to dry dressings are unnecessary because the tissue does not need debridement. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.
A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? 1.Foam 2.Alginate dressing 3.Hydrocolloid dressing 4.Semipermeable transparent film
4.Semipermeable transparent film Rationale: The client's wound has moderate drainage. Recall that foam, alginate, and hydrocolloid dressings are applied to wounds with moderate to heavy drainage. Semipermeable transparent films are applied to dry wounds.
The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. 1.Deep tissue injury 2.Stage II pressure ulcer 3.Stage III pressure ulcer 4.Stage IV pressure ulcer
4.Stage IV pressure ulcer Rationale: In a stage IV pressure ulcer, there is full-thickness tissue loss with exposed bone, tendon, or muscle. Eschar or slough may be present in some parts of the wound. In a stage II pressure ulcer, there is partial-thickness loss of the dermis manifesting as a shallow open ulcer with a pink/red wound bed and no slough. In a stage III pressure ulcer, there is full-thickness tissue loss with subcutaneous fat visible but no exposure of tendon or muscle, and slough may be present. Deep tissue injury appears as localized areas of purple or maroon discolored intact skin or a blood-filled blister.
The home health care nurse makes a home visit to a client who has an ulcer on the medial aspect of the left ankle. The wound is being treated with a hydrocolloid dressing. The nurse removes the hydrocolloid dressing, cleanses the wound as prescribed, and reapplies the hydrocolloid dressing. The nurse schedules the next visit for wound care and changing the hydrocolloid dressing in how many days, which is the maximum number of days? Fill in the blank
7 days Rationale: The nurse would schedule the next home care visit in 7 days. Protective hydrocolloid dressings are designed to be left in place for 7 days unless leakage occurs around the dressing or the wound gel appears to have migrated beyond the margins of the wound. However, the dressing will need to be changed sooner if increased exudate is present.
A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. 1.Fever 2.Vasodilation 3.Inflammation 4.Deoxygenated hemoglobin 5.Excessively high environmental temperature
1,2,4,5 Erythema (or redness) of the skin can be caused by vasodilation from high environmental temperatures, fever, or inflammation. The presence of deoxygenated hemoglobin is responsible for cyanosis of the skin.
Isotretinoin is prescribed for a client with severe cystic acne. The nurse provides instructions to the client regarding administration of the medication. Which phrase stated by the client indicates a need for further teaching regarding this medication? 1."I need to continue to take my vitamin A supplements." 2."The medication may cause dryness and burning in my eyes." 3."I need to use emollients and lip balms for my dry skin and lips." 4."I will need to return for a blood test to check my triglyceride level."
1."I need to continue to take my vitamin A supplements." Rationale: In severe cystic acne, isotretinoin is used to inhibit inflammation. Adverse effects include elevated triglyceride levels, skin dryness, eye discomfort such as dryness and burning, and cheilitis (lip inflammation). Close medical follow-up is required, and dry skin and cheilitis can be decreased by the use of emollients and lip balms. Vitamin A supplements are stopped during this treatment.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken. 5.Place a sterile saline dressing and ice packs over the wound. 6.Place the client in a supine position without a pillow under the head.
1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken. Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching? 1."I will inspect my skin daily." 2."I can sit in my favorite chair all day." 3."I need to drink at least 2 liters of fluid daily." 4."I will make sure that my skin is clean and well moisturized."
2."I can sit in my favorite chair all day." Rationale: Sitting in one position all day can be a risk factor for pressure ulcer development. Options 1, 3, and 4 are preventative measures for pressure ulcer development.
A client has been given diphenhydramine as a topical agent for allergic dermatitis. The nurse should instruct the client to observe for which intended medication effect? 1.Nighttime sedation 2.A decrease in urticaria 3.Healing of burned tissue 4.Resolution of ecchymosis
2.A decrease in urticaria Rationale: Diphenhydramine reduces the symptoms of allergic reaction, such as itching or urticaria, when used as a topical agent on the skin. When taken orally it may provide mild nighttime sedation. It is not used to treat burns or ecchymosis.
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1.An inflammation of the epidermis only 2.A skin infection of the dermis and underlying hypodermis 3.An acute superficial infection of the dermis and lymphatics 4.An epidermal and lymphatic infection caused by Staphylococcus
2.A skin infection of the dermis and underlying hypodermis Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis.
The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for? 1.Lichenification with scaling and excoriation 2.Lesions with well-defined geometric margins 3.Bright red erythematous macules and papules 4.Evolution of lesions from vesicles to weeping papules and plaques
2.Lesions with well-defined geometric margins Rationale: Contact dermatitis findings include skin lesions with well-defined geometric margins. Option 1 describes a medication eruption. Option 3 describes nonspecific eczematous dermatitis. Option 4 describes atopic dermatitis.
A client is seen in the clinic for a complaint of scalp itching that has been persistent over the past several weeks. After an assessment, it is determined that the client has head lice. Permethrin shampoo is prescribed, and the nurse provides instructions to the client regarding the use of the medication. The nurse should tell the client to take which measure? 1.Put the medication in 1 time only. 2.Leave the medication in for at least 4 hours. 3.Wash, rinse, and towel-dry the hair before applying. 4.Leave the shampoo on for 8 to 12 hours and then remove by washing.
3.Wash, rinse, and towel-dry the hair before applying. Rationale: Permethrin is toxic to adult mites and lice but less toxic to the ova. For this reason, retreatment may be required. It is required to wash, rinse, and towel-dry the hair before applying the medication. It is left in for 10 minutes and removed by a warm water rinse. Therefore, options 1, 2, and 4 are incorrect.
Sodium hypochlorite is prescribed for a client with a leg wound that is draining purulent material. The home health nurse teaches a family member how to perform wound treatments. Which statement, if made by the family member, indicates a need for further teaching? 1."A fresh solution needs to be prepared frequently." 2."I should rinse the solution off immediately after the irrigation." 3."The solution should not come in contact with normal skin tissue." 4."I will soak a sterile dressing with solution and pack it into the wound."
4."I will soak a sterile dressing with solution and pack it into the wound."
The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? 1.Venous stars noted on trunk and thighs 2.Spider angiomas observed on trunk and thighs 3.Appears to have purpura on trunk and thighs 4.Appears to have cherry angiomas on trunk and thighs
4.Appears to have cherry angiomas on trunk and thighs A cherry angioma occurs with increasing age and has no clinical significance. It is noted by the appearance of small, bright, ruby-colored round lesions on the trunk and/or extremities. A venous star results from increased pressure in veins, usually in the lower legs, and has an irregularly shaped bluish center with radiating branches. Spider angiomas have a bright red center, with legs that radiate outward. These are commonly seen in those with liver disease or vitamin B deficiency, although they can occur occasionally without underlying pathology. Purpura results from hemorrhage into the skin.
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding 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 of the dermis
4.Partial-thickness skin loss of the dermis In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.
