Study guide Skin Midterm

A nurse is reinforcing teaching to a client about skin cancer. Which of the following statements by the client indicates a need for further teaching? reinforcing teaching to a client about skin cancer. Which of the following statements by the client indicates a need for further teaching? A. "Eating a high fiber diet will reduce my risk for developing skin cancer." B. "I should check my skin monthly for any changes." C. "I should avoid the use of tanning booths.". D. "I should use sunscreen even on cloudy days."

A. "Eating a high fiber diet will reduce my risk for developing skin cancer." Rationale: The nurse should inform the client that a high fiber diet is recommended to reduce the risk of colon cancer, not skin cancer.

A nurse is reinforcing teaching with a client who has genital herpes caused by herpes simplex virus type 2 (HSV 2). Which statement by the client indicates understanding of the teaching? A. "I can transmit the infection to another person even when I don't have symptoms." B. "I will need a 7 day course of antibiotics to treat this infection." C. "My partner and I will use a condom for sexual intercourse when I have lesions present." D. "The first indication of HSV 2 is a hard, red, painless sore."

A. "I can transmit the infection to another person even when I don't have symptoms." Rationale: Transmission of HSV 2 can occur even when the client has no symptoms. Viral sheddIng can occur even when lesions are no longer present.

A nurse is assisting with the development of an education program about skin cancer. Which of the following information should the nurse include in the presentation? A. "Individuals who have light skin are at greater risk for developing skin cancer." B. "Tanning bed use should be limited to once per week." C. "Basal cell carcinoma has a high rate of metastasis." D. "A family history of squamous cell carcinoma is a risk factor for developing skin cancer.'

A. "Individuals who have light skin are at greater risk for developing skin cancer." Rationale: Individuals who have light skin and those over the age of 60 are at increased risk for developing skin cancer.

A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection? A. Change gloves between sites when providing wound care to multiple wounds. B. Place new linen on the client's bed every other day. C.Monitor vital signs every 4 hr. D. Change the dressing on infected wounds first.

A. Change gloves between sites when providing wound care to multiple wounds. Rationale: To prevent cross-contamination of wounds, the nurse should wear sterile gloves during all dressing changes and wound care activities. The nurse should change glov es when providing wound care to a new wound site on a different area of the client's body.

A nurse is reinforcing infection control practices for hand hygiene with a group of unit nurses. Which of the following information should the nurse reinforce in the teaching? A. Change gloves between tasks on the same client. B. Keep artificial nails trimmed short. C. Use alcohol-based hand rubs before administering eye drops for a client. D. Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile.

A. Change gloves between tasks on the same client. Rationale: The nurse should include in the teaching to change gloves between tasks on the same client to prevent cross-contamination of microorganisms

I nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound? A. Granulation tissue on the surface of the wound B. Musty odor from the foam dressing upon removal. C. Sanguineous drainage in the suction device. D. Peeling of the edges of the transparent dressing

A. Granulation tissue on the surface of the wound As the wound heals, the nurse should expect the wound base to become reddor as granulation tissue lines the surface of the wound. Therefore, this is an expected fi nding. The vacuum-assisted closure device assists in wound closure by applying a localized negatrye pressesalin draw the edges of the wound together. The device co nsists of a suction tube embedded in a foam dressing. The foam dressing is applied to the wound bed and sealed in place with an occlusive dressing The suction is th en attached to the vacuum unit, causing the foam to collapse and resulting in drainage of excess fluids, and increasing circulation to the wound bed.

A nurse is collecting data from a client who has multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? A. Irregular borders B. Purulent drainage C. Uniform pigmentation D. Intense pruritus

A. Irregular borders Rationale: Findings associated with malignant changes in a nevus include asymmetry, irregular borders, non-uniform pigmentation, and increased diameter. Therefore, the nurse should report irregular borders on any of the nevi to the findings to the provider.

A nurse is caring for a client who states he has a nevus that has increased in size and changed in color. On examination, the nurse notes an elevated two centimeter lesion that is dark brownish-black in color with irregular borders. The nurse should recognize that these findings are consistent with which of the following medical diagnoses? A. Malignant melanoma B. Basal cell carcinoma C. Squamous cell carcinoma D. Kaposi's sarcoma

A. Malignant melanoma Rationale: These findings are consistent with malignant melanoma which is associated with changes in preexisting nevi.

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect? • A. Reports of exposure to a skin irritant B. Denial of pruritus C. Elevated temperature . D. Reports of joint discomfort

A. Reports of exposure to a skin irritant Rationale: A common cause of contact dermatitis is exposure to a topical irritant; therefore, identifying this irritant is an important component of data collection.

A nurse is reviewing the medical history of a client who is scheduled for surgery. Which of the following findings places the client at risk for an incisional hematoma? A. The client takes anticoagulant medications. B.The client has peripheral vascular disease. C.The client has urinary incontinence. D.The client is underweight

A. The client takes anticoagulant medications.

A nurse is inspecting a lesion on a client who has basal cell carcinoma. Which of the following findings should the nurse expect? A.A pearly, shiny nodule B.A red, edematous macule C.A rough, scaly tumor D.A weeping vesicle

A.A pearly, shiny nodule

A nurse is preparing to assist with irrigating a wound for a client. Which of the following actions should the nurse plan to take? A.Irrigate the wound until the solution that is draining is clear. B.Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating. C.Flush the wound from the most contaminated area to the cleanest area. D.Chill the irrigant prior to the procedure.

A.Irrigate the wound until the solution that is draining is clear

A nurse is assisting with teaching a class about the function of cells in the epidermis. The nurse should include that which of the following cells determine skin color? A.Melanocytes B.Merkel cells C. Keratinocytes D.Langerhans cells

A.Melanocytes

A nurse is caring for a client who has recurrent herpes simplex type 1 lesions. The nurse should perform a focused assessment of which of the following areas of the client's body A.Mouth B.Genitalia C.Extremities D.Scalp

A.Mouth Rationale: Herpes simplex type 1 most commonly occurs on the client mouth

A nurse is assisting with teaching a newly licensed nurse about reducing the risk for healthcare-associated infections. Which of the following instructions should the nurse include? A.Use chlorhexidine gluconate to clean skin on clients who are preoperative B.Provide mouth care every 8 hrs for clients who require mechanical ventilation C.Irrigate indwelling urinary catheters daily. D.Change a gauze dressing over central vascular access devices every 3 days

A.Use chlorhexidine gluconate to clean skin on clients who are preoperative

A nurse is reinforcing teaching with a client about the risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "Because I have a light complexion, I have a decreased risk for skin cancer.". B. "I need to use sunscreen even in winter." C. "I used to lie in the sun all the time, but now I just go to the tanning bed." D. "My father was treated for melanoma, but skin cancer isn't related to genetics."

B. "I need to use sunscreen even in winter." Rationale: The client should use sunscreen daily to minimize the negative effects of ultraviolet rays. The vast majority of cases of skin cancer diagnosed each year are considere d to be sun related.

A nurse is reinforcing teaching with a client who has a skin lesion and is scheduled for an excisional skin biopsy. Which of the following information should t include in the teaching? A. "You will not be able to have breakfast until after the procedure." B. "You will need to change the dressing daily." C. "You will need to take oral antibiotics for 7 days following the procedure." D. "You will need to have the sutures removed in 4 days by your provider."

B. "You will need to change the dressing daily." Rationale: The nurse should instruct the client that a dressing will be applied after the biopsy which will need a daily dressing change.

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection? A. A client who has serosanguineous drainage from the wound B. A client who has swelling and tenderness around the wound C. A client who has urticaria and itching around wound D. A client who has brown crusting over the wound

B. A client who has swelling and tenderness around the wound Rationale:Manifestations of infection include purulent drainage, swelling, warmth, tenderness around the wound, and a failure to heal.

A nurse in a provider's office is collecting data from a client who reports pruritus and reddened, fluid-filled vesicles on her lower leg. The nurse should suspect which of the following disorders? A. Cellulitis B. Contact dermatitis C. Folliculitis D. Seborrheic dermatitis

B. Contact dermatitis Rationale: Contact dermatitis is an acute or chronic skin inflammation that results from direct skin contact with chemicals or allergens. Typical findings include erythema (redness), pruritus (itching), vesicles, and scales.

A nurse is caring for a client following the application of an aqua thermia pad. Which of the following manifestations should the nurse identify as an indication that the client has a superficial burn? A. Blistering. B. Erythema.. C. Leathery skin. D. Waxy skin

B. Erythema. Rationale:Erythema is a manifestation of a superficial burn.

A nurse is caring for a client who has widespread psoriasis. The nurse should prepare the client for which of the following treatments? A. Radiation therapy B. Exposure to photochemotherapy Rationale: Photochemotherapy combined with mediation treatment, through the use of ultraviolet light, has been shown to be effective in the treatment of widespread psoriasi S. C. Topical application of antibiotic ointment D. Administration of isotretinoin

B. Exposure to photo chemotherapy Rationale: Photo chemotherapy combined with mediation treatment, through the use of ultraviolet light, has been shown to be effective in the treatment of widespread psoriasiS.

A nurse is discussing alopecia with a client who is to begin chemotherapy. Which of the following statements should the nurse include? A. Placing a tourniquet around the scalp before treatment can reduce hair loss. B. Hair loss is common and includes eyebrows and eyelashes. C. Hair loss is typically permanent D. Any hair regrowth is usually the same color and texture as before.

B. Hair loss is common and includes eyebrows and eyelashes. Rationale: The nurse should inform the client that alopecia occurs as a whole-body hair loss for most clients administered chemotherapy

A nurse in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia? A. Clammy skin B. History of poor wound healing. C. Report of decreased urinary output D. Random blood glucose 126 mg/dL

B. History of poor wound healing. Rationale:The presence of hyperglycemia leads to poor wound healing due to decreased blood supply to the tissue.

A nurse is assisting with teaching a class about the function of cells in the epidermis. The nurse should include which of the following are receptor cells that detect light touch? A.Melanocytes B. Merkel cells C.Keratinocytes D. Langerhans cells

B. Merkel cells

A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take? A. Apply dry, sterile gauze dressings to affected areas. B. Prepare to administer acyclovir. C. Instruct family with a history of chickenpox that they should not visit the client. D. Apply topical corticosteroids to the affected areas.

B. Prepare to administer acyclovir. Rationale: Acyclovir is effective in the treatment of herpes zoster, especially if administered within the first 2 to 3 days of the eruption.

A nurse is collecting data from a client following a bee sting. Which of the following findings can indicate an anaphylactic reaction to the venom? a nurse is collecting data from a client following a bee sting. Which of the following findings can indicate an anaphylactic reaction to the venom? A. Bradycardia. B. Urticaria C. Nausea and vomiting. D. Generalized edema

B. Urticaria Rationale: Urticaria or the appearance of hives can signal the onset of an anaphylactic reaction.

A nurse is reinforcing health teaching about skin cancer with a group of clients. Which of the following risk factors should the nurse identify as the leading cause o non-melanoma skin cancer? A. Exposure to environmental pollutants. B. sun exposure C. History of viral illness. D. Scars from a severe burn

B. sun exposure Rationale: According to evidenced-based practice, the nurse should identify exposure to the sun as the leading cause of non-melanoma skin cancer. Ultraviolet light radiation fr om the sun can cause cancerous changes in the skin. Decreased ozone protection has increased the amount of radiation exposure and increased the risk of cancer for clients regardless of skin color.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? A.A client who alert and responsive and eats 25% of each meal. B.A client who is unresponsive to verbal commands and changes position occasionally. C.A client who makes frequent slight changes in position and walks occasionally. D. A client who is receiving enteral feeding and can change position independently.

B.A client who is unresponsive to verbal commands and changes position occasionally.

A nurse in a provider's office is collecting data from a client who reports pruritus and reddened, fluid-filled vesicles on her lower leg. The nurse should suspect which of the following disorders? A.Cellulitis B.Contact dermatitis C.Folliculitis D.Seborrheic dermatitis

B.Contact dermatitis

A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? A Increased collagen B.Decreased circulation C.Increased muscle mass Decreased serum calcium

B.Decreased circulation

A nurse is assisting with the care of a client who is incontinent. Which of the following actions should the nurse take? A.Restrict the client's fluid intake. B.Dry between folds in the client's skin. C. Clean the client's skin with hot water. D.Apply baby powder to the client's skin.

B.Dry between folds in the client's skin.

A nurse is contributing to the plan of care for a client who has a superficial wound with no exudate. Which of the following dressings should the nurse recommend to cover the wound? A. Foam dressing B.Film dressing C. Alginate dressing D.Hydrofiber dressing

B.Film dressing

A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition? A.Itching and scratching of the head B.Firmly attached white particles on the hair C.Patchy areas of hair loss D.Thick, yellow-crusted lesions on a red base

B.Firmly attached white particles on the hair

A nurse is collecting data from a client who reports finding a new skin lesion. winich of the following actions is the nurse's priority? A. Document the client's history of skin allergies. B.Identify when the client first noticed the lesion. C. Photograph the lesion for the client's medical record. D. Instructing the client on the use of daily sunscreen products.

B.Identify when the client first noticed the lesion. Rationale: The first action the nurse should take using the nursing process is to collect data from the client. Therefore, the priority is to determine when the lesion was first discovered.

A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include? A Maturation B.Inflammation C.Remodeling phase D.Proliferation

B.Inflammation

A nurse is collecting data on a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect? A Full thickness skin loss with visible bone B.Intact skin with localized erythema C.Full thickness skin loss with visible adipose tissue. D.Partial-thickness skin loss with red tissue in wound bed

B.Intact skin with localized erythema

A nurse is collecting data from a client who has AIDS. The nurse notes that the client has multiple, widespread purplish-brown skin lesions. The nurse should suspect that the client has developed which of the following types of skin lesions? A.Actinic keratosis B.Kaposi's sarcoma C.Actinic dermatitis D.Basal cell carcinoma

B.Kaposi's sarcoma

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include? A. "Use a soft bristle brush to gently rub the affected areas." B. "Take a hot shower daily to relieve itching.' C. "Wear loose fitting clothing while you are experience itching." D. "Add fabric softener to linens when they are washed."

C. "Wear loose fitting clothing while you are experience itching." Rationale: The nurse should advise the client that to help relieve the itching of pruritus, the home environmental temperature should be slightly cool and the client should wear loose clothing

A nurse is assisting with the care of a client who is brought to the emergency department and has burn injuries. Which of the following findings should the nurse identify the client has a deep partial-thickness burn? A. Burned area black in color and pain absent B. Burned area pink in color with blisters C. Burned area red in color with eschar present. D. Burned area yellow in color with severe edema

C. Burned area red in color with eschar present Rationale:This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain.

A nurse is caring for a client who was admitted to the emergency department immediately following a snake bite to her forearm. The client suspects that the snake was venomous. Which of the following nursing interventions is appropriate? A. Apply an ice pack to the site of the bite.. B. Apply a tourniquet just above the elbow.. C. Determine the need for a tetanus immunization. D. Elevate the client's forearm.

C. Determine the need for a tetanus immunization. Rationale:Clients who have a puncture wound to the skin due to a snakebite are at risk for tetanus because the fangs of the snake can be contaminated with bacteria from soil or feces. Therefore, the nurse should ask the client when she had her last tetanus immunization.

A nurse is collecting data on a client's wound. The nurse observes that the wound surface is covered with soft. this is a manifestation of which of the following? A. Decreased perfusion B. Infection C. Granulation tissue D. An inflammatory response

C. Granulation tissue RationaleGranulation tissue forms in healing wounds during the proliferative phase. Granulation tissue is soft, red tissue

A nurse is collecting data from a client who has herpes zoster (shingles). Which of the following is an expected finding? A. Blisters at the corners of the mouth B. Fluid-filled vesicles in the genital area C. Painful vesicles following a nerve pathway D. Pustules scattered over the ribcage

C. Painful vesicles following a nerve pathway Rationale: Clients with shingles have painful vesicles that are distributed along infected nerve pathways.

A nurse is caring for a client who has suspected superficial spreading melanoma. When collecting data about the client's lesion, which of the following is an expected finding? A. Pain. B. Pruritus C. Purplish in color D. Purulent drainage.

C. Purplish in color Rationale: Dark pigmentation of the lesion is an expected finding of malignant melanoma

A nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching? A. Herpes zoster is only contagious to others who have had chickenpox B. The client is contagious only if the lesions are draining. C. Recurrence of infection can be triggered by stress or trauma. D. Recovery occurs in 6 to 8 weeks.

C. Recurrence of infection can be triggered by stress or trauma. Rationale: The virus remains in the body in a dormant state in the nerve ganglia and the client is asymptomatic. Recurrence of herpes zoster is triggered by physiological stressors such as trauma, fever, or malignancy.

A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take? A. Massage the client's bony prominences B. Keep the head of the bed elevated. A Rationale: C. Reposition the client at least every 2 hr. D. Keep the client's skin moist.

C. Reposition the client at least every 2 hr. Rationale:The nurse should change the client's position at least every 2 hr to stimulate circulation and prevent pressure ulcers.

A nurse in a health clinic is assisting in the planning of an educational program on skin cancer. Which of the following statements should be included in th presentation? A. Squamous cell carcinoma occurs most often on the face and trunk.. B. Radiation therapy is the treatment of choice for metastatic skin cancer. C. Sun exposure as a child is a significant risk factor for skin cancer. D. Basal cell carcinoma is an aggressive cancer with a high rate of metastasis.

C. Sun exposure as a child is a significant risk factor for skin cancer. Rationale: Sunburn as a child is a significant risk factor for the development of skin cancer, with blue-eyed blondes and redheads as the most susceptible.

A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority? A. The client has large blistered areas over his chest. B. The client has decreased sensation over the burn areas. C. The client produces black colored sputum. D. The client has edema at the burn site.

C. The client produces black colored sputum. Rationale: When using the urgent vs. non urgent approach to client care, the nurse determines the priority finding is black colored sputum which is a manifestation of smoke inhalation and can lead to pulmonary failure and respiratory distress.

A nurse is assisting with the development of a teaching plan for a client who has psoriasis. Which of the following statements should the nurse include in the plan? A. Wash the affected area with hot water. B. Treatment will focus on pain management. C. Treatment will include coal tar preparations. D. Apply warm moist compresses to the affected areas.

C. Treatment will include coal tar preparations. Rationale: Coal tar preparations are used in the treatment of psoriasis; therefore, the nurse should include this treatment in the teaching plan.

A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings? A.Fluid volume overload B.Kidney stones C.Dermatitis D.Hypoglycemia

C.Dermatitis

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include? "A.Use a soft bristle brush to gently rub the affected areas." B."Take a hot shower daily to relieve itching." C.Wear loose fitting clothing while you are experiencing itching." D."Add fabric softener to linens when they are washed."

C.Wear loose fitting clothing while you are experiencing itching."

A nurse is contributing to the plan of care for a client who has herpes zoster. Which of the following actions should the nurse recommend including in the plan of care? A. Restrict visitors who have not previously received a measles, mumps, and rubella vaccine. B. Place the client in protective isolation. C. The nurse should avoid the use of alcohol-based hand rubs while caring for this client. D. Apply cool compresses to the affected area.

D. Apply cool compresses to the affected area. Rationale. Clients who have herpes zoster often complain of itching and pain over the affected area. Applying calamine lotion and cool compresses can assist in decreasing these manifestations

A client arrives for initial evaluation following a diagnosis of systemic lupus erythematosus (SLE). The nurse understands that which of the following is a classic cutaneous manifestation of SLE? A. Facial pallor B. Brittle nails C. Foot ulcers D. Butterfly rash on face.

D. Butterfly rash on face Rationale: The nurse should identify a butterfly rash as a common cutaneous manifestation for the client who has SLE. Other common findings include hair loss, weakness, ant sun sensitivity resulting in a widespread rash.

A nurse is caring for a client who is 6 days postoperative from abdominal surgery. The nurse observes that the client's wound is in evisceration. Aft which of the following actions should the nurse take next? A. Raise the head of the bed. B. Place the client supine with knees bent. C. Assess for manifestations of shock. D. Cover the area with a sterile dressing, moistened with saline.

D. Cover the area with a sterile dressing, moistened with saline. Rationale: The greatest risk to this client is injury to the internal tissue. Therefore, the priority first action is to cover the client's wound with a sterile dressing moisten 9% saline.

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse see? A. A dry raised rash B. Excessive salivation C. Periorbital edema D. Hardened skin

D. Hardened skin Rationale: Hardened, tight skin is an expected finding with scleroderma. In addition to rigid skin and subcutaneous tissue also cause disorders of the heart, lungs and kidneys.

A nurse in the outpatient clinic is collecting data from a client who has psoriasis. Which of the following findings should the nurse expect? A. Lesions along the pathways of nerve endings B. Serous drainage C. Intense pain D. Silvery, white scales

D. Silvery, white scales Rationale: The characteristic lesions of psoriasis are thick, erythematous plaques covered by silvery scales.

A nurse is reinforcing teaching with a client who has a superficial lesion. A biopsy indicates malignant melanoma. Which of the following treatment choices should the nurse include in the teaching? A.Cryosurgery B.Chemotherapy C.Radiation therapy D. Surgical excision

D. Surgical excision

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer? A. There appears to be persistent reddening of the skin. B. There is slough on part of the wound area. C. There is a fluid-filled area under the skin. D. There is full-thickness skin loss with a crater.

D. There is full-thickness skin loss with a crater. Rationale: The nurse describes a stage 3 pressure ulcer.

A nurse is assisting with obtaining an aerobic wound culture for a client. Which of the following actions should the nurse recommend taking first? A.Place the collection tube in a specimen bag. B.Swab the wound bed with a sterile cotton-tipped swab C.Cleanse the area around the wound with sterile saline. D.Don sterile gloves

D.Don sterile gloves

A nurse is assisting with the care of a client who has an infected wound with significant exudate. Which of the following dressings should the nurse plan to cover the client's wound? A.Polymeric membrane dressing B.Hydrogel dressing C.Hydrocolloid dressing D.Hydrofiber dressing

D.Hydrofiber dressing

A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect? A.Intact skin with localized erythema. B.Full thickness skin loss with visible adipose tissue C.Full thickness skin loss with visible bone D.O Partial-thickness skin loss with red tissue in wound bed.

D.Partial-thickness skin loss with red tissue in wound bed.

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take? A.Connect the drain to continuous low-pressure suction. B.Empty the drainage device when it is half full. C.Clean the skin near the drain in a circular motion from the outside to the inside. D.Place a perforated gauze pad around the drain.

D.Place a perforated gauze pad around the drain

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? A.Elevate the head of the client's bed 45° B.Reposition the client every 4 hr. C.Massage the client's bony prominences. D.Provide the client with a high-calorie diet.

D.Provide the client with a high-calorie diet.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? A.Sanguineous B.Serous C.Serosanguineous D.Purulent

D.Purulent

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection? A. Petechiae • B. Edema C.Urticaria D.Crusting over granulated tissue

• B. Edema Rationale:Manifestations of infection include purulent drainage, swelling warmth, tenderness around the wound, and a failure to heal.