Unit 4
A client at 36 weeks gestation is admitted with thrombophlebitis. The client is on strict bed rest, vital signs every 4 hours, fetal heart tones every 4 hours, and an intravenous heparin drip. The client is concerned about the effect the drug might have on her baby. She states, "If it makes my blood thinner, then won't it make my baby's blood change?" Which response by the nurse would be most appropriate?
"Heparin doesn't cross the placenta, so it can't get into the baby's blood system."
The nurse reinforces the client's teaching on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional instruction has been effective?
"I chose a baked potato with broiled chicken for dinner."
A nurse is reinforcing education for a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates that education has been effective?
"I'll eat plenty of fruits and vegetables."
The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?
"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."
A nurse is reinforcing education for a client on testicular self-examinations and testicular cancer. Which information should the nurse include?
"Testicular cancer is one of the highly curable types of cancer."
A female client is scheduled to undergo abdominal surgery for possible ruptured tubal pregnancy. A nurse is witnessing the client's signature on a consent form. Which client statement would the nurse interpret as the best indicator of the client's informed consent?
"The health care provider may have to remove my fallopian tube if it has burst."
A nurse is reinforcing preoperative instructions for a client scheduled for an appendectomy. Which statement regarding postoperative pain control is most appropriate?
"To manage your pain well you should take the pain medication before pain becomes intense."
The nurse is caring for a 15-year-old who has suffered third degree burns to 30% total burn surface area (TBSA). The health care provider has order morphine 0.5 mg by mouth every 3 to 4 hours as needed for pain. The elixir comes in 2mg/1 ml. How many milliliters would the nurse give? Record your answer using two decimal places.
0.25
The client arrives in the emergency department after a burn injury that occured in their home basement and inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?
100% oxygen via a tight-fitting, nonrebreather face mask
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse calculates that he has sustained burns to which percentage of his body?
27%
A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection?
3 to 7 days
A licensed practical nurse is assisting a triage nurse in the emergency department admit a client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned?
36
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what percentage of the total body surface area has been burned?
36%
The nurse is working in a pediatric emergency department. Which client would the nurse see first?
5 year old with orbital cellulitis
A nurse is assisting with the development of a care plan for a client with impaired wound healing. Which client would be a risk factor for this diagnosis? Select all that apply.
60-year-old client with impaired mobility secondary to a CVA 75-year-old client with poorly controlled diabetes
The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavax vaccine for the prevention of shingles?
62-year-old client that had a mild case of shingles 4 years previously
A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema?
Administer tepid baths, and use moisturizers immediately after the bath
A client who is dissatisfied with the current hospitalization decides to leave against medical advice (AMA) and refuses to sign the paperwork. Which action by the nurse would be most appropriate?
Allow the client to leave after providing information about the possible consequences of leaving.
A topical corticosteroid is prescribed by the health care provider for a child with contact dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?
Apply a thin layer of cream and rub it into the area thoroughly.
A topical corticosteriod is prescribed by the healthcare provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?
Apply a thing layer of cream and rub it into the area thoroughly.
The nurse is changing a dressing and providing wound care. Which activity should the nurse perform first?
Assess the client's wound-related pain.
The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply.
Back Soles of feet Palms of hands
A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply.
Be sure to wear shower shoes when using a public shower. Change socks at least once a day. Keep skin clean and dry.
A client is concerned about severe abdominal pain. During the focused assessment, the nurse asks which question to elicit as much information as possible about the pain?
Can you describe the pain?
A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce?
Monitor your temperature for signs of infection.
A client with a history of duodenal ulcers states to the nurse, "I take antacids once in a while to relieve the pain." Which statement by the client should be reported immediately?
My bowel movements have been sticky and black.
When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation perforation, and surgery. Based on which evidence, why is the nurse selecting this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
Which intervention by a nurse might help prevent pressure ulcers?
Placing an alternating-current mattress on the client's bed
The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?
Positive culture results
The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?
Positive culture results
A nurse receives an assignment to provide care to 10 clients. Two of them have had kidney transplantation surgery within the last 36 hours. The nurse feels overwhelmed with the number of clients. In addition, the nurse has never cared for a client who has undergone recent transplantation surgery. What are the appropriate actions for the nurse to take? Select all that apply.
Speak to the charge nurse about the assignment. Document all concerns in writing about the assignment.
A parent brings a child to the health care provider's office because the child reports pain, redness, and tenderness of the left index finger. The child is diagnosed with paronychia. Which organism is the most likely cause of this superficial abscess of the cuticle?
Staphylococcus species
The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce?
Take the drug 1 hour before or 2 hours after meals with large amounts of water.
Which of the following correctly defines puerperium?
The 6 weeks following birth
The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a horse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?
The burn has probably cause laryngeal edema, which has occluded the airway
The nurse is reviewing a client's goals and expected outcomes on the plan of care. The nurse expects that the goals will incorporate which statements? Select all that apply.
The goals are measurable. The goals include target dates for achievement.
The nurse is caring for a child in the burn unit who sustained partial thickness burns to the lower extremities. What does the nurse determine the nutritional needs of this child will be?
The hypermetabolic state after a burn injury can lead to poor healing if not corrected.
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?
The return of distal pulses
The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adquacy of the fluid resuscitation?
Urine output
The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice?
White sacs attached to the hair shafts in the occipital area
The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of?
a client outcome
A nurse is caring for several clients. Which client is at greatest risk for aspiration?
a client that had a stroke with dysarthria
A client with a diagnosis of diabetes insipidus is being treated with desmopressin acetate. The client asks, "What is this medication?" What is the best response by the nurse?
a synthetic vasopressin
Which challenges faced by older adult clients should the nurse consider when implementing care?
adjusting to decreased physical strength and coping with deaths of family and friends
A postoperative client has just been admitted to a unit from the postanesthesia care unit (PACU). When should the nurse change the dressing for the first time?
after the surgeon changes the first dressing and provides the written orders
A nurse is collecting data on a client with possible osteoarthritis. What factor places this client at the greatest risk for osteoarthritis?
age
A nurse is assigned to care for a client in the immediate postoperative recovery phase. Which data collection takes priority during the initial assessment?
airway, respiratory rate and depth, other vital signs, and skin color
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction would best prevent skin damage?
apply sunscreen even on overcast days
A client has been admitted with burns on both legs. Which nursing intervention is most important to help prevent contractures?
applying knee splints
The nurse completes a wet-to-dry dressing change on a client's lower extremity wound. When should the nurse document the dressing change?
as soon as they finish the dressing change
The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client?
avoid exposure to the sun
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?
compromised skin graft
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?
contact isolation
A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:
dislodge the autografts
The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?
dry, cracked lips, strawberry tongue
A client is ordered a dose of epoetin alfa to treat anemia related to chemotherapy. The recommended dose is 150 units/kg. The client weighs 60 kg. The vial is labeled 10,000 units/mL. How many milliliters of epoetin alfa should the nurse administer? Record your answer using one decimal place.
0.9
A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?
identifying one way to increase social interaction
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?
impaired gas exchange
The nurse is caring for a 4-year-old with a full-thickness burn. Before sending the child to hydrotherapy for a scheduled wound debridement, which nursing action is a priority?
implement pain control measures
A nurse is caring for a client who has just had a liver biopsy. Which nursing intervention is the priority after the biopsy?
keep the client on bed rest, lying on right side
A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize?
lean meats and low-fat milk
The nurse is assisting with the care of a neonate born to a mother with type 1 diabetes. When gathering data on the neonate, the nurse would suspect that the neonate is experiencing hypoglycemia based on which finding?
lethargy
The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have?
measles
An older adult client with pneumonia is having difficulty managing respiratory secretions and clearing the airways. Which nursing intervention would be most appropriate?
monitor the need for suction every hour
The nurse is caring for a client with a diagnosis of conversion disorder. Which clinical symptoms does the client demonstrate that correlate with this diagnosis?
neurologic symptoms associated with psychological conflict or need
Which of the following is the most numerous type of white blood cell (WBC)?
neutrophil
A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client?
nonsteroidal anti-inflammatory drugs (NSAIDs)
A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition?
orthostatic hypotension
The nurse is admitting a client who states, "I was bit by a brown recluse spider." Which observations made by the nurse would indicate the client's report is accurate?
painful rash around a necrotic lesion
A client has been hospitalized with a diagnosis of acute arterial occlusive disease. After surgery, the health care provider orders heparin IV therapy for the client. What test does the nurse need to monitor for this client while on heparin?
partial thromboplastin time (PTT)
A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best?
performing mouth care
A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. How should the nurse document the findings?
petechiae
A nurse is caring for a client with suspected acute pulmonary edema. What nursing intervention should the nurse perform to promote oxygenation?
place the client in high Fowler position
Which nursing intervention should the nurse give highest priority to when caring for an unconscious client?
positioning the client with the head of bed at a 15 to 30 degree angle
The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the health care provider?
potassium level 6.2 mg/dL
A client who was voluntarily admitted to an inpatient psychiatric unit suddenly begins yelling, throws a chair, and exhibits extreme agitation. Which consideration would be most important for the nurse to keep in mind when addressing the client's current behavior?
restraints should be used only as a last resort
The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.
restrict exercise
The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?
ring or donut
The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:
risk manager
A nurse is evaluating the effectiveness of therapy with acetylcysteine in a child with acetaminophen poisoning. Which laboratory values would be most important for the nurse to monitor?
serum alanine aminotransferase (ALT)
The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present?
silver-white scaly lesions
The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called?
statue of limitations
A nurse is caring for a client with a seizure disorder. This nurse should instruct the client to avoid which activity until the seizures are controlled by medication?
swimming
A client gave birth vaginally to a healthy, full-term baby girl 2 hours ago. When gathering data on this postpartum client, which finding would the nurse report immediately?
tachycardia accompanied by hypotension
The nurse observes a ring-shaped rash that has a red raised border and a clearer center on the upper arm. The client asks the nurse what kind of rash it is. What is the best response by the nurse?
tinea corporis
A client is admitted to an inpatient psychiatric unit. After data collection and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in a specific corner of the dayroom." The nurse is communicating these planned nursing interventions for which main rationale?
to establish a trusting relationship
A client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should:
turn him frequently
The nurse is collecting data on a client admitted with second- and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
urine output of 20 mL/hour
The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing?
wash hands thoroughly
The nurse is told that an assigned client is suspected of having methicillin-resistant Staphyloccus aureus (MRSA). Which precautions should the nurse institute during the care of the client?
wear a gown and glasses
A 12-year-old child with cystic fibrosis (CF) is prescribed pancrelipase for a trypsin deficiency. When reinforcing education with the child and parents, how does the nurse instruct them to administer the pancrelipase?
with meals and snacks
A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client?
wound care nurse
The nurse is changing a client's dressing. Which observations would require the nurse to immediately notify the health care provider? Select all that apply.
yellow, purulent drainage client complains of increasing pain
When collecting data on a child with cellulitis, which symptoms would the nurse expect to find?
fever, edema, tenderness, and warmth at the site
A child fell at camp and sustained a bruise to the thigh. Which description would accurately describe the bruise after 1 week?
greenish yellow
The health care provider prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question prior to administration?
heparin sodium
A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse?
"I will call the physician with this information."
A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. He also reports nausea, diaphoresis, and shortness of breath. What should the nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
A parent is preparing for the imminent death of a child due to sickle cell anemia. The parent has been unable to eat or sleep and talks only about the impending loss and feelings of guilt for the child's pain and suffering. Which nursing intervention has the highest priority?
Allow the parent to express feelings without judgement.
Which action by the nurse displays client advocacy during a skin assessment?
Ensuring client privacy by pulling the curtain closed
A client with bulimia nervosa tells a nurse he/she was doing well until last week, after having a fight with a parent. Which nursing intervention would be most helpful?
Examine the relationship between feelings and eating.
Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale?
Excessive use can have adverse effects, such as skin atrophy and fragility.
A client with obesity is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?
Identify alternative ways for the client to lose weight
A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
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?
Partial-thickness skin loss of the dermis
A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. What action should the nurse take to assist the client with coping?
Provide a referral to the Cancer Society or another support program.
A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP?
Put a washcloth in the sink to prevent damage the dentures.
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?
Tinnitus
The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching?
hold the cane on the opposite side of the injury
A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child?
hypokalemia
When collecting data on a client during a routine checkup, the nursing student reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. The student asks the nurse what is aphthous stomatitis? What is the nurse's best response?
"Aphthous stomatitis is a canker sore of the oral soft tissues."
A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."
A 15-year-old comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that the parents might be notified of the test results. Which response by the nurse is most appropriate?
"HIV testing is confidential; after we get the test results, we will discuss your options with you only."
A client with a weak left leg is learning how to ambulate with a cane; however, he has difficulty remembering to hold the cane with his right arm. Which statement by the nurse would be most helpful to this client?
"Remember to hold the cane with the hand on the opposite side of your weak leg."
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?
"Take a shower immediately, lathering and rinsing several times."
A nurse reinforces the homecare instructions for a client diagnosed with basal cell epithelioma. Which statement by the client indicates an understanding of the instructions?
"The best time of the day to work outside is before 10 a.m. and after 2 p.m."
The nurse reinforces information about self-detection for cancer to a group of adolescent male clients. Which statement made by one of the participants indicates that the client understands the information?
"The best time to check for testicular changes is after a warm bath."
A nurse is reviewing the care plan of a client who has been receiving an intravenous solution. What appropriate expected outcome for this client should the nurse expect to find on the care plan?
"The client remains free of signs and symptoms of phlebitis."
Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
"The medication is likely to cause stinging every time it is applied."
The nurse is caring for a client who is blind. Which is the best way for the nurse to assist with ambulation?
Have the client take the nurse's arm, with the nurse walking slightly ahead of the client.
A healthcare provider informs a client that the client's diagnosis of ovarian cancer is terminal. The client, usually religiously observant, is expressing rage at God and the clergy. Which nursing intervention is appropriate for this client?
Help the client use effective coping strategies.
A licensed practical nurse (LPN) who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short-staffed. The nurse has never worked in a CCU. Which action by the nurse would be most appropriate?
Identify the tasks that the nurse feels he or she can safely perform on arriving at the CCU.
A nurse is caring for a client who is awaiting surgery for a hip fracture. Which nursing intervention has the highest priority when providing skin care for this client?
Keep the skin clean and dry without using harsh soaps.
Which intervention has the highest priority when providing skin care to a bedridden client?
Keeping the skin clean and dry without using harsh soaps
A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.
A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, what should the nurse plan to speak with the client's family about?
Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours
While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." When creating the nursing care plan, which diagnosis would the nurse select to accurately reflect this information?
Risk for impaired skin integrity related to immobility
A client with a neurogenic bladder is beginning bladder training. Which nursing action is most important?
Set up specific times for the client to empty the bladder.
An LPN is assigned to care for eight clients. Two unlicensed assistive personnel are assigned to work with this nurse. The LPN integrates understanding of which statement when delegating client care assignments to the unlicensed assistive personnel?
The nurse is responsible for supervising the two unlicensed assistive personnel.
A nurse is caring for a client with a pressure ulcer. Which nursing interventions are appropriate for this client? Select all that apply.
Turn and reposition the client at least every 2 hours. Post a turning schedule at the client's bedside and adapt position changes to the client's situation.
A nurse collects data on a client who is postoperative thyroid surgery. The client has a positive Chvostek's sign. Which laboratory finding supports the presence of this finding?
calcium 7.1 mg/dL (1.77 mmol/L)
A client newly diagnosed with type 2 diabetes is admitted to the metabolic unit for treatment initiation and education. Which information should the nurse reinforce to this client as a goal for treatment?
exercise and weight reduction diet
The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?
"Lesions most often are located on the arms and chest."
The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.
- A delay in growth may occur after a burn injury. - An immature immune system presents an increased risk of infection for infants and young children. - Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.
The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.
A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults.
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.
A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight
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?
A skin infection of the dermis and underlying hypodermis
A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand?
A white color of the skin which is insensitive to touch
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?
A white color to the skin, which is insensitive to touch
Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?
Apply the lotion to cool, dry skin at least 30 minutes after bathing.
The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?
Adequacy of capillary filling
The nurse, employed at a long term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff members to the client with a diagnosis of herpes zoster?
An unlicensed assistive personnel who has never had chicken pox
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?
At least 30 minutes before exposure to the sun
The nurse is caring for a client with curcumferential burns of both legs. Which leg position is appropriate for this type of burn?
Elevation about the level of the heart
The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin?
Fine grayish red lines
The licensed practical nurse is collecting a wound culture from a client's gaping surgical incision. Which would the nurse consider to ensure proper culture collection?
Gently roll a sterile swab from the center of the wound outward to collect drainage.
A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?
Hyperventilation
The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by the client indicates the need for further teaching?
I need to avoid sun exposure before 10am and after 4pm
The nurse is reinforcing home-care instructions to parents of a 3-year-old child with scabies. Which statement by the parent indicated a need for further teaching?
I understand I need to leave the scabicide on for 4 hours before washing it off.
A client returns to the clinic for follow up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of lesion? Select all that apply.
It is highly mestatic Lesion is a nevus that has changed in color
The nurse is reviewing the healthcare record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documents in the client's record? Select all that apply.
Lesion has a waxy border An irregularly shaped lesion
A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply.
Lesion is highly metastatic. Lesion is a nevus that has changes in color.
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
Mafenide acetate
The nurse is instructing a client after the administration of a Mantoux test. Which statement from the client indicates an understanding of the information given by the nurse?
Mantoux test is a screening for tuberculosis
After sustaining a stroke, a client is transferred to the rehabilitation unit. A medical-surgical nurse reviews the client's residual neurological deficits with a rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?
Urinary incontinence and right-sided hemiparesis
When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply.
Monitor the skin for breakdown daily during client's bath. Keep skin clean and dry to prevent breakdown. Turn and reposition the client every two hours.
The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action?
Move the victim to a safe area away from the snake and encourage the victim to rest.
The evening nurse reviews the nursing documentation in the male 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 of the following would the nurse expect to note on assessment of the client's sacral area?
Partial-thickness skin loss of the epidermis
When talking with the parents of a child with erythema infectiosum (fifth disease), the nurse should include which statement?
Pregnant women are at risk for fetal death if infected with fifth disease.
The nurse is performing wound care on a client. Which task indicates surgical asepsis?
Preparing sterile surgical instruments for the physician to debride the wound
The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculous capitis (head lice). Which should be included in that list? Select all that apply.
Siblings may also need treatment Grooming items such as combs and brushes should not be shared Launder all bedding and clothing in hot water and dry on high heat Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.
The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?
The child is 18 months old.
Each member of the family of a child diagnosed with pinworms is prescribed a single dose of mebendazole. Which statement would the nurse incorporate into the reinforcing teaching plan?
The dose may be repeated in 2 weeks
The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply.
The nurse who never had chickenpox The nurse who never received the varicella-zoster vaccine
The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which 1227 characteristics as improvement in the manifestations of psoriasis? Select all that apply.
Thinner and decrease in number of reddish papules Scarce amount of silvery-white scaly patches on the arms
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?
Triglyceride level
The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply.
Use sunscreen when participating in outdoor activities Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious
A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication?
Vitamin A
Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?
White blood cell count of 3000 mm3 (3.0 × 109/L)
The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?
White sacs attached to the hair shafts in the occipital area.
A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster?
a 76-year-old client taking immunosuppressant medication
A family that recently went camping brings their child to the clinic with a report of a rash after a tick bite. Which finding should the nurse expect to see in a child with Lyme disease?
bright rash with red outer border circling the bite site
A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:
cancer of the cervix
A child was found unconscious at home and brought to the emergency department by the fire and rescue unit. While collecting data, the nurse observes cherry-red mucous membranes, nail beds, and skin. Which cause is the most likely explanation for the child's condition?
carbon monoxide poisoning
A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition?
carbon monoxide poisoning
When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately?
horsness of the voice
Which finding should the nurse anticipate when evaluating the skin of an older adult client?
inelastic skin turgor
The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid to treat acne. The nurse determines that which client complaint may be associated with use of this medication?
itching
When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance.
A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs?
measure intake and output
The nurse is assisting with the education of a community group about the prevention of melanoma. What statement indicates that reinforcement of education is required?
melanoma usually has defined borders
A nurse in the emergency department is caring for a client with burns on the upper torso. What is the priority nursing action?
monitor respiratory status
A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug?
ototoxicity
A client reports being exposed to lice and thinks he or she may have them. Which observations made by the nurse would indicate the client's report is correct?
oval, white dots stuck to the hair shafts
The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis?
pruritic papules, pustules, and linear burrows of the finger and toe webs
The nurse is gathering data from a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which observation most likely supports this finding?
purulent drainage on a soiled wound dressing