tissue integrity self-quiz

a nurse in a burn treatment is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. the client's spouse asks the nurse what the procedure entails. which of the following nursing statements is appropriate? a. "large incisions will be made in the eschar to improve circulation." b. "this produce involves placing the client into a shower and removing the dead tissue." c. "a piece of healthy skin will be removed from an unburned area and grafted over the burned area." b. "dead tissue will be non-surgically removed."

a.

a nurse in a long-term care facility is caring for an older adult who had a stroke 4 weeks ago and who is unable to move independently. the nurse should monitor for which of the following complications of immobility? a. a reddened area over the sacrum b. stiffness in the lower extremities c. difficulty moving the upper extremities d. difficult hearing some types of sounds

a.

a nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. while planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? a. airway obstruction b. infection c. fluid imbalance d. paralytic ileus

a.

a nurse is caring for a client who is immobile. which of the following actions is the priority for the nurse to include in the client's plan of care? a. accurate breath sounds at least every 2 hours b. perform range-of-motion (ROM) exercises at least two to three times daily c. make sure the client has an intake of 2,000 to 3,000 mL of fluid per day d. apply anti embolic stockings

a.

a nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. the nurse should recommend which of the following foods as the best source of protein to promote wound healing? a. one cup of brown rice b. one cup of orange juice c. one cup of pureed avocado d. one cup of lentils

d.

a nurse is reviewing the laboratory results of a client who has a pressure ulcer. the nurse should identify an elevation in which of the following laboratory valves as an indication that the client has developed an infection? a. BUN b. potassium c. RBC count d. WBC count

d.

a nurse is caring for a client who has an electrical burn. with the client's permission, the nurse is answering questions from the family about his status. which of the following responses should the nurse make? a. "he is doing well, although he might be in the hospital for some time." b. "he has an electrical burn. he is unstable, and we will update you with any changes." c. "he has an electrical burn, which caused coagulation of some tissues." d. "he does not appear to hav much damage and should be fine soon."

b.

a nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. which of the following interventions should the nurse include in the plan? a. apply a heat lamp twice a day b. reposition the client at least every 2 hours c. clean the wound with hydrogen peroxide solution d. massage reddened areas with dressing changes

b.

a nurse is caring for an older adult client who is at risk for skin breakdown. which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. reposition the client every 3 hours b. massage bony provinces to promote circulation c. provide the client with a diet high in protein d. apply cornstarch to keep the skin dry

c.

a nurse is planning care for a client who is confined to bed. which of the following actions should the nurse include in the plan? a. massage the client's red bony prominences b. assess the client's skin for increased coolness c. reposition the client every 2 hours d. keep the client's skin moist

c.

a nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. which of the following nursing actions are appropriate? (select all that apply) a. massage over erythematous bony prominences b. implement turning schedule every 4 hours c. use pillows to keep heels off the bed surface d. keep the client's skin dry with powder e. minimize skin exposure to moisture

c. e.

a nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. what is the nurse's priority intervention for this client during the resuscitation of phase of injury? a. initiate fluid resuscitation b. medicate for pain c. insert an indwelling urinary catheter d. maintain the airway

d.

a nurse is an emergency department is caring for a client who has burns on the front and back of both his legs and arms. using the rules of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? a. 9 percent b. 18 percent c. 36 percent d. 54 percent

d.

a nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. which of the following interventions should the nurse include in the plan? a. soak in sitz bath for 20 minutes after each stool b. administer a soap-suds enema to cleanse the colon c. cleanse with antimicrobial serum and vigorously dry d. wipe perianal with warm and apply a barrier cream

d.

a nurse is planning care for an older adult client who is at risk for developing pressure ulcers. which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. use a transfer device to lift the client up in bed b. apply cornstarch to keep sensitive skin areas dry c. massage the skin over the client's bony prominence d. elevate the head of the bed no more than 45*

a.