Week 2: Integumentary Disorders
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider?
IV rate increase The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin.
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
IgE Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.
A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?
"On the morning of the surgery, I can shave my surgical area at home to save time." The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections. Washing with an antibacterial soap for a few days before surgery reduces the skin's bacterial count. The client shouldn't use lotions or cosmetics on the day of the surgery. The client can shower before coming to the hospital.
A client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate?
Administer pain medication as ordered. A pain rating of 7 out of 10 indicates significant pain. Therefore, the most appropriate action would be to administer pain medication as ordered. The nurse can ask the client what makes the pain better after medication has been given. Providing diversional activities is appropriate only after administration of pain medication. It isn't appropriate to not treat the client's pain
After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?
After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?
A client who is taking aspirin caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which action first?
Apply an ice pack for 20 minutes. Aspirin has an antiplatelet effect and bleeding time can consequently be prolonged. Intermittent use of ice packs to the site may stop the bleeding; ice causes blood vessels to vasoconstrict. Use of lukewarm water, patting the injury, and wrapping the entire forearm do not promote vasoconstriction to stop bleeding.
The nurse is applying a hand mitt restraint for a client with pruritus (see figure). What should the nurse do first?
Verify the prescription to use the restraint. Before using any restraints, the nurse must verify that a health care provider (HCP) has written a prescription for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmar surface of the hand.
A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used.
Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing. The correct order for a dressing change involves the nurse washing her hands, putting on gloves, removing the dressing, and observing the drainage.
he nurse anticipates the transfer of which burn clients to a burn center? Select all that apply.
an adult with 1.5% total body surface area (TBSA) third-degree burns of face an adult with an electrical burn a child with burns of hands and feet Major burn injuries include second-degree burns > 25% in adults or > 20% in children, any electrical injuries, and any burns involving eyes, ears, face, hands, feet, perineum, and joints
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?
urine output of 30 mL/h Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but this is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypovolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?
"I'll eat plenty of fruits and vegetables." For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to take in these nutrients. The treatment of the ulcer may or may not include covering it; a wound nurse would create the best plan for the client. Redness in a wound is a sign of inflammation.
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 is the total body surface area that has been burned?
36% The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.
A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:
4 hours. Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.
The nurse is providing care to a pediatric client having an anaphylactic reaction. Place the below nursing assessments in order based on priority. All options must be used.
Assess respiratory rate. Listen to breath sounds. Palpate and compare pulses. Assess level of consciousness. Obtain a brief history. Ask if the child has received any medication since the onset of symptoms. Assessment of respiratory rate establishes if the client is breathing and if the airway is adequate. Assessment of breath sounds determines the patency of the airway. Palpating pulses determines if circulation is sufficient. Those are all priority assessments. Then LOC can be assessed. History and medications can be assessed after the client is stabilized.
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse take?
Cover the area with sterile gauze that is moistened with sterile saline solution. Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. Although providing support to reduce the client's anxiety is important, it is not the priority nursing action. The abdomen should not be wrapped with dry gauze. This would enhance drying of the protruding organs and could lead to tissue and organ necrosis. The supine position with the legs extended will place pressure on the abdominal structures, increasing pain and possibly exacerbating the evisceration. The client should be positioned with the legs bent to relax the abdominal muscles.
A client with right-sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity?
Turn the client regularly. The most important intervention for maintaining skin integrity is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure is not relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and pressure injuries. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but does not prevent pressure injuries. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair, but it does not prevent the development of pressure injuries. Massage of bony prominences will restore circulation to that area; however, it should not be done if the skin over the area is reddened, as this would hasten the development of a pressure injury.
Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?
client with a compromised skin graft A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy is not used to improve the oxgyenation status of a client with chronic obstructive pulmonary disease or pneumonia. This type of treatment would not encourage bone healing after a fracture.
When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer?
exposure to moisture Exposure to moisture can lead to maceration and the development of pressure ulcers. It is important for the client's skin to be kept clean and dry with prompt attention to cleanliness after incidents of incontinence. The client's gender and the presence of hypertension are not factors leading to pressure ulcers. Smoking affects the oxygen status of the client but does not directly lead to the development of pressure ulcers.
The nurse is caring for a client who has deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, there will be a fluid shift from the:
intravascular to the interstitial compartment. During the emergent phase of burn management, there is a massive shift of fluid from the blood vessels (intravascular compartment) into the tissues (interstitial compartment). The result of this shift is hypovolemic shock and edema formation. The fluid shift is caused by increased capillary permeability that allows water, sodium, and protein to shift to the tissues. As the emergent period ends and capillary permeability returns to normal, the fluid in the interstitial compartment will return to the intravascular compartment.
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
mafenide The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Gamma benzene hexachloride is a pediculicide used to treat lice infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.
the nurse should assess a client for which complications associated with disseminated intravascular coagulation (DIC)?
pulmonary embolism Pulmonary embolism is an indication of intravascular clotting due to the fact that platelets have been significantly decreased and there is clotting and bleeding. Low prothrombin levels will also show that there is a delay in clotting, so the person will bleed for a longer time. The other conditions are not associated with DIC.
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
scale A scale is the characteristic secondary lesion occurring in psoriasis. A fissure is a linear crack with sharp edges that extends into the dermis. An erosion is a wearing-away of the superficial epidermis layer causing a moist, shallow depression. A papule is a reddened elevated area. Psoriasis does not cause fissues, erosions, or papules.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?
stage II pressure ulcer Stage I pressure ulcers appear as nonblanching macules that are red in color. Stage II ulcers have breakdown of the dermis. Stage III ulcers have full-thickness skin breakdown. In stage IV ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.
The nurse is performing triage in the emergency department. Which client should be seen first?
the client with burns to the chest and neck with singed nasal hair The client with burns to the chest and neck has the potential to develop decreased lung expansion. Singed nasal hair indicates an inhalation injury, which may lead to the development of respiratory distress syndrome. Flank pain that radiates to the groin is an indication of renal calculi, but this would not take precedence over a client with an obstructed airway. The fracture is not life-threatening and would not take precedence over the client with airway problems. The primipara still has time before the baby comes.
The rate at which IV fluids are infused is based on the burn client's:
total body weight and BSA burned. During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.
A client with a major burn injury is receiving fluid resuscitation. Which assessment finding indicates that this treatment has been effective?
urine output at 0.5 mL/kg/hour Hourly urine output is often used as an indicator of effective fluid resuscitation, with about 0.5 mL/kg/hr for an adult considered adequate. Blood pressure changes are less reliable because significant hypotension does not develop until volume losses exceed 30%. Degree of orientation is not used as an indicator of adequate fluid resuscitation. If fluid resuscitation is adequate, the heart rate should be lower than 120 beats/minute or in the upper limits of normal for the client's age. However, the fear, anxiety, and pain that accompany burn injuries often increase the heart rate.
A client is admitted with a 45% partial and full thickness burn. Which finding would alert the nurse that the client has a deficiency in fluid volume during the first 24 hours?
urine output of less than 30 mL/hr It is critical that the nurse monitor the vital signs, hemodynamics and urine output during the emergent and resuscitative phase of the burn injury. The urine output of less than 30 mL/hr is an indication of hypovolemia in this client. The serum creatinine, serum potassium, and the oxygen saturation level are all within acceptable limits.
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child's home with six other people. During the client's visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is
"All family members need to be treated." When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.
A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would be most appropriate?
"Take a warm tub bath or shower before exercising. This may help with your discomfort." Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.
A healthcare provider orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
"To prevent evaporation of water from the hydrated epidermis." The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer. An emollient does not affect the rate of skin cell growth. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient does not prevent skin inflammation
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate?
Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure. A sunscreen with an SPF of 30 or higher should be worn on all sun-exposed skin surfaces. It should be applied before sun exposure and reapplied after being in the water. Peak sun exposure usually occurs from 0010 to 1400. Tightly woven clothing, protective hats, and sunglasses are recommended to decrease sun exposure. Sun tanning parlors should be avoided.
Which question is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis?
Do you have any pets?" An infected pet may be the source of this infection. The other questions are appropriate to ask when obtaining a health history related to skin disorders but are not the priority question.
A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth. Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin. What does the nurse instruct the client to do prior to beginning the medication?
Enroll in a risk management plan. Because of the risk of birth defects with isotretinoin, risk management plans require all clients to meet certain requirements to obtain the medication. Providers are advised to closely monitor clients for signs of depression, but a mental health evaluation is not universally required. It is not sufficient to begin a single form of effective method of birth control with the first dose of the medication. Women of childbearing age must use two forms of effective birth control for 1 month before, during, and 1 month after taking the drug. Isotretinoin may cause muscle aches, and extreme exercise should be avoided, but general participation in sports should be considered on an individual basis.
A client has been admitted with a left tibial fracture and extensive soft-tissue injuries, and there is a concern for the development of disseminated intravascular clotting (DIC). Which interventions by the nurse are priorities for this client? Select all that apply.
Improve tissue oxygenation, replace fluids, and correct electrolyte imbalances. Assess for any signs of bleeding in the gums and other mucous membranes. It is most important that tissue oxygenation be preserved, as circulation is impaired. In addition, fluid replacement and correction of electrolyte imbalance is critical. It is also a priority to assess for any signs of bleeding, as this can be an early indicator of DIC. The mortality rate can be 80% in clients who develop disseminated intravascular clotting. The priorities are not replacement of blood or administering antihypertensive medications.
The nurse is assessing a client with dark skin for the presence of a stage I pressure ulcer. Which is the best approach to making this assessment?
Look for skin color that is darker than the surrounding tissue. When assessing a client with dark skin for the presence of a pressure ulcer, the nurse should observe for skin that is darker, brownish, purplish, or bluish compared to surrounding skin. Fluorescent light casts a blue light, making skin assessment difficult; natural or halogen light sources help to accurately assess the skin. Risk assessment using the Braden Scale should be performed on all clients. A Braden score of 12 indicates a high risk for pressure ulcer, and the lower the Braden score, the higher the risk (no risk 19 to 23, at risk 15 to 18, moderate risk 13 to 14, high risk 10 to 12, and very high risk 9 or below). The nurse should touch the skin to assess consistency and temperature differences.
Which action should the nurse take to provide effective emergency care at the accident site for a victim with a heat burn?
Pour cool water over the burned area. The recommended emergency treatment for a heat burn is immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue.The burn should be kept moist to prevent the dressing adhering to the wound.Warm, mild soap solutions would be contraindicated because they are irritating to the injured tissue.Antiseptics or ointments are contraindicated because they can lead to further tissue damage.
A client with acquired immunodeficiency syndrome (AIDS) is ordered zidovudine, 200 mg P.O. every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
Take zidovudine every 4 hours around the clock." to be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may
dislodge the autografts. Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.
Which nutritional deficiency may delay wound healing?
lack of vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.
A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?
ring or donut The nurse should not use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface.
The nurse is working as charge on a medical-surgical unit and is working with a graduate nurse who has been on orientation for the past 4 weeks. Which client should the charge nurse assign to the new nurse?
a client who requires a dressing change of a pressure ulcer The new graduate would be competent to perform skills such as sterile dressing change taught in school. Clients whose care requires more experience, such as complex skills, and education, such as admission assessments, pre-procedure teaching, and discharge teaching, should be assigned to more experienced RN staff members because these nurses are aware of the organizational procedures and have completed them routinely.
he nurse is working as charge on a medical-surgical unit and is working with a graduate nurse who has been on orientation for the past 4 weeks. Which client should the charge nurse assign to the new nurse?
client who requires a dressing change of a pressure ulcer The new graduate would be competent to perform skills such as sterile dressing change taught in school. Clients whose care requires more experience, such as complex skills, and education, such as admission assessments, pre-procedure teaching, and discharge teaching, should be assigned to more experienced RN staff members because these nurses are aware of the organizational procedures and have completed them routinely.
Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts:
promote the growth of epithelial tissue. Biologic dressings such as porcine grafts serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue.
A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when the nurse applies pressure and observes for color change when pressure is released and the skin color changes to:
reddish. When pressure is applied to the skin, the area first becomes blanched, or whitish. When pressure is relieved, the circulation tends to carry excess blood to the area to make up for the temporary decrease in blood supply. This effect, called reactive hyperemia, causes the skin to redden. Such a reddened area is a precursor of a pressure ulcer.Bluish skin indicates a lack of oxygen in the tissues, not the development of a pressure ulcer.Whitish skin may be indicative of arterial insufficiency to an area.A yellowish cast when blanched suggests jaundice, which indicates a liver or biliary tract disorder.
Which nursing diagnosis is the priority for a client with burns to 35% of the body surface area?
risk for infection The greatest risk to a client with burns to more than 25% of the body is infection and sepsis, which can be fatal. Therefore, the priority is to acknowledge that the client is at risk for infection and to implement interventions that address this. The other diagnoses, although applicable to a burn client, are not the priority.
When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch?
roast beef sandwich, milkshake, and cottage cheese A roast beef sandwich, milkshake, and cottage cheese would provide the burn victim with the extra protein and calories needed for healing.The other meals provide fewer calories and less protein than is optimal and would not be the preferred choice for the client with severe burns.
The nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. Which position would be most appropriate for preventing contractures?
supine Supine in extension is the position most likely to prevent contractures. Clients who have experienced burns will find a flexed position most comfortable. However, flexion promotes the development of contractures. The high Fowler's and semi-Fowler's positions create hip flexion. The prone position is contraindicated because of head and neck burns. In clients with head and neck burns, pillows should not be used under the head or neck to prevent neck flexion contractures.
The nurse is collaborating with the dietician to plan the diet of a client with a latex allergy. Which foods should not be included in the client's meal plan? Select all that apply.
tomato soup grapes potatoes Foods with known cross-reactivity to latex include tomatoes, grapes, and potatoes, as well as many others. Therefore, these foods should be avoided by someone with a latex allergy. Macaroni and cheese and green beans are safe for the client to consume.
The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home?
use of smoke detectors The majority of burns that occur in the home can be prevented with the use of working smoke detectors. The nurse should encourage members of the community to have working smoke detectors throughout the home. Although placement and accessibility of fire extinguishers, ease of initiating an emergency response system, and eliminating the use of candles may all aid in reducing the risk of burns in the home, they are not as effective as the use of smoke detectors.
The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?
Apply a hydrocolloidal dressing. Full-thickness skin loss occurs in a stage 3 pressure injury. WIth this type of injury, subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Treatment of this type of injury includes the use of a hydrocolloidal dressing because it forms an occlusive barrier over the area while maintaining a moist environment; this prevents infection, friction, and shear. The extremity should be elevated to reduce pain and improve blood flow. The area should not be cleansed with hydrogen peroxide as this will harm granulation tissue and prevent healing. The injury should be wrapped with sterile gauze to prevent infection. Protein intake should be encouraged to promote wound healing. Fluids should be encouraged to maintain adequate hydration for skin integrity.
A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. During the past few weeks, the client has been spending less time in the wheelchair and, when in the wheelchair, uses a cushion. During the appointment the nurse notes that the client is not using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen?
Ask the client to explain the treatment regimen. It is important to first assess what the client knows about the treatment regimen. The nurse should then provide further teaching in terms that the client understands; this should be done after an assessment of what the client knows. The client should be using a cushion to sit on to reduce pressure, and the wound should be kept moist to promote healing. Care decisions can be made by the client; however, the nurse must ensure that the client has available knowledge to make an informed decision. Calling the family may be an option, but the client should be the first one to explore what is known about the treatment. Providing an in-depth explanation about the anatomy and physiology of pressure ulcer development is not necessary.
The nurse is caring for an immune-compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?
Avoid sharing combs and brushes. Tinea capitis is a fungal infection of the scalp that occurs in hot, humid environments. Risk factors include exposure to daycare centers or pets with the infection, poor hygiene, diabetes, immune system disorders, and the sharing of combs, brushes, or hats. Washing the hair helps, but dandruff-preventing shampoo will not prevent the condition. The health problem can occur with any length of hair.
A client with rheumatoid arthritis states, "I cannot do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?
Conserve energy. Based on the information from the client, the nurse should develop a plan with the client that will conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may have difficulty coping, but that is not the current concern. Employing cleaning services may not be within the client's budget, and the client should first try a plan that balances rest and activity.
When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assitant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?
Document the findings. The nurse must first document the assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. The nurse must follow the chain of command. The nurse isn't a manager or supervisor and may not have the authority to administer discipline. Although it might be appropriate for the nurse to make an incident report, the nurse doesn't yet have adequate information to prepare a complete report.
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority
Ineffective airway clearance related to edema of the respiratory passages When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water. The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.
the nurse is assessing a client with dark skin for the presence of a stage I pressure ulcer. Which is the best approach to making this assessment?
Look for skin color that is darker than the surrounding tissue. When assessing a client with dark skin for the presence of a pressure ulcer, the nurse should observe for skin that is darker, brownish, purplish, or bluish compared to surrounding skin. Fluorescent light casts a blue light, making skin assessment difficult; natural or halogen light sources help to accurately assess the skin. Risk assessment using the Braden Scale should be performed on all clients. A Braden score of 12 indicates a high risk for pressure ulcer, and the lower the Braden score, the higher the risk (no risk 19 to 23, at risk 15 to 18, moderate risk 13 to 14, high risk 10 to 12, and very high risk 9 or below). The nurse should touch the skin to assess consistency and temperature differences.
A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?
a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place. Although option 1 describes a large wound, it's showing signs of healing, so a consult isn't necessary. Option 2 describes a stage II wound that has a clean wound bed; a wound nurse consult isn't necessary for this type of wound. The wound described in option 4 is small and shows signs of healing; a wound care consult isn't required at this time.
When should the nurse initiate rehabilitation plans for the client who has severe burns?
after the client's circulatory status has been stabilized Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.
The nurse plans to administer an injection of heparin to a client. Which technique for heparin administration is appropriate? The nurse:
applies gentle pressure to the site for 5 to 10 seconds after the injection. Gentle pressure should be applied after the injection, but the area must not be massaged. Heparin is administered subcutaneously, never intramuscularly. A 25- or 26-gauge, ½- to 5/8-inch (1.3- to 1.6-cm) needle is most appropriate for heparin administration. The fatty layer of the abdomen is the preferred injection site. The nurse should select a site 1 to 2 inches (2.5 to 5 cm) away from the umbilicus, scar tissue, or any bruises. To decrease the risk of hematoma formation and tissue damage, aspiration of the plunger should be avoided.
A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:
autonomy. Autonomy is the right of the individual to make his own decisions. In this case, the client is capable of making his own decision and the nurse should support his autonomy. Beneficence, promoting and doing good, and justice (being fair) aren't the principles that directly relate to the situation. Advocacy is the nurse's role in supporting the principle of autonomy.
The nurse should assess a client who is in the emergent phase of burn management for:
hyperkalemia. Owing to the massive cellular destruction that occurs in burns, potassium is released into the extracellular fluid, which leads to hyperkalemia.Hemoconcentration, not hemodilution, is caused by circulatory dehydration as plasma shifts into the extracellular space.Metabolic acidosis, not alkalosis, commonly develops due to loss of bicarbonate ions.Hyponatremia, not hypernatremia, is another anticipated electrolyte imbalance because sodium is trapped in edematous fluid.
A client has a diagnosis of dehydration. What indicators would the nurse assess to determine an improvement in dehydration? Select all that apply.
increased weight increased blood pressure The client with dehydration and risk for skin breakdown would need the weight assessed to determine an increase with improved fluid retention. An increased blood pressure and decreased, not increased, heart rate would indicate an improvement in fluid volume. The client's skin turgor would be increased, not decreased, with increased fluid intake as well. The fluid volume increase would cause neck veins that are more distended, not flat, which indicates an increase in circulating blood volume.
A client reports a firm, red nodule with a scaly crust on the back. What is the best nursing intervention?
notify the healthcare provider. Squamous cell carcinomas are malignant lesions that are generally found on areas of sun-damaged skin and are usually characterized by firm, red nodules with scaly crusts. The client should be assessed by the healthcare provider; the nurse should not recommend applying lotion or reminding client to wear sunscreen until the healthcare provider has assessed this condition.
The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)?
obtaining a wound culture during a dressing change A LPN/VN's scope of practice includes obtaining wound cultures and changing dressings. Teaching, assessment, and planning of care are complex actions that should be carried out only by the RN.
A triage nurse in the emergency department admits a male 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? Record your answer using a whole number.
36 The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%.
The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do next?
Contact the health care practitioner (HCP) to request a hydrocolloid dressing. The pressure ulcer has changed from stage I to stage II and requires the use of a protective dressing. Repositioning and use of foam mattresses are appropriate interventions for stage I pressure ulcers. While the daughter can take pictures and send them to the nurse, it is the nurse's responsibility to make decisions about needed care. Telehealth monitoring equipment is providing sufficient visualization of the skin changes; the nurse does not need to make a home visit at this time.
The nurse is teaching a female client about taking folic acid supplements for folic acid deficiency anemia. What information should be included in the teaching plan?
Oral contraceptive use, pregnancy, and lactation increase daily requirements. Oral contraceptive use, pregnancy, and lactation are situations that increase demand for folic acid. With supplementation, a response should cause the reticulocyte count to increase within 2 to 3 days after therapy has begun. It is not necessary to take folic acid on an empty stomach. A client may safely take both iron and folic acid supplementation.
A nurse is preparing a care plan for a client burned over 36% of their body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?
The client's complete blood count readings reflect a reduced hematocrit During the intermediate phase of burn care, the client's hematocrit should diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues. In the intermediate phase of burn care, the client will experience serum sodium deficits. Urinary output increases during this phase as renal perfusion increases. Loss of serum sodium leads to metabolic acidosis, not metabolic alkalosis.
A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?
The dressing should keep the wound moist. A wet-to-damp saline dressing should always keep the wound moist. Tight or dry packing can cause tissue damage and pain. A dry gauze dressing — not a plastic sheet-type dressing — should cover the wet dressing.
Which information should the nurse include when providing discharge instructions to a client with psoriasis?
Trim fingernails regularly. Clients with psoriasis are likely to experience itching. Trimming nails will help to prevent damage to the client's skin caused by scratching. Applying creams after bathing may help to reduce itching. Scrubbing vigorously when bathing should be avoided, as it can cause bleeding. Using a washcloth on skin is considered to be too harsh and should be avoided.
A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply
Use pressure-reduction devices." "Reposition every 1 to 2 hours." "Teach the family how to care for the wound." "Clean the area around the ulcer with mild soap." Using a pressure-reduction device, repositioning every 2 hours, and cleaning the area around the wound with a mild soap will aid in healing or will prevent further skin breakdown. Teaching the family how to care for the wound will assist with discharge planning. Protein, not carbohydrate, intake should be increased to promote wound healing. Support-surface therapy is a major therapeutic method for managing pressure, friction, and shear on tissues.
Which step must be done first when administering a blood transfusion?
Verify the physician's order. The nurse must first verify the physician's order and then make sure the informed consent form is signed. Next, the nurse should make sure that an appropriate-size I.V. catheter is in place and the nurse should assess the site for patency. After doing so, the nurse should verify the blood product and client identity with another nurse.
When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers?
a client who has a decreased serum albumin level Risk factors for the development of pressure ulcers include poor nutrition, indicated by a decreased serum albumin level. According to the Guidelines for Pressure Ulcers published by the Agency for Healthcare Research and Quality, other risk factors include immobility, incontinence, and decreased sensation. A client who does not ambulate often can be repositioned frequently to prevent pressure ulcers. Having an indwelling urinary catheter does not normally increase the risk of developing a pressure ulcer unless pressure from the tubing impinges on urethral or other tissue. An elevated white blood cell count does not place a client at risk for pressure ulcers.
During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring?
applying continuous-compression wraps Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring.
The nurse is caring for a resident in a long-term care facility who has venous stasis ulcers and is being treated with an Unna boot. Which of the nursing activities is best for the nurse to delegate to a unlicensed assistive personnel (UAP)?
assist the client in cleaning around the Unna boot. The Unna boot is a non-elastic paste bandage boot that can be used to treat uninfected, non-necrotic leg and foot ulcers that result from such conditions as venous insufficiency and stasis dermatitis. The dressing wraps around the affected foot and leg. The boot's effectiveness results from compression applied by the bandage, which decreases edema, combined with moisture supplied by the paste. An Unna boot is contraindicated in clients who are allergic to any ingredient used in the paste and in clients with arterial ulcers, weeping eczema, or cellulitis. Evaluating the boot effectiveness, the foot sensation/movement, and capillary refill, in addition to teaching the family about the signs of infection, are tasks for the nurse with more education and a license.
A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?
behind the ears Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.
client with heart failure is admitted to the hospital. What should the nurse assess in the client to determine a risk for impaired skin integrity? Select all that apply.
crackling breath sounds auscultated over lung fields increase in blood pressure from 122/76 to 144/90 neck vein distention with head of bed at 90 degrees Clients with fluid volume excess related to heart failure have an increased risk for impaired skin integrity. Assessment findings for excess fluid volume include crackling breath sounds, increased blood pressure, and neck vein distention. Having weight gain of 1 pound over a month would not necessarily be indicative of fluid volume excess as this would likely be seen over a much shorter period of 2-3 days instead and usually more than 1 pound (0.5 kg) change. Grading of a 2+ pulse indicates a normal finding and the client would have a more bounding pulse (3-4+) with fluid volume excess.
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?
droplet precautions Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators.
At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress note and begins planning client care based on which nursing diagnosis?
fear related to potential diagnosis of malignant melanoma Documentation reveals that the client is anxious about the symptoms. These symptoms most closely resemble malignant melanoma. Therefore, fear related to potential diagnosis of malignant melanoma is the most appropriate nursing diagnosis. The nursing note does not indicate that the client presently has deficient knowledge. The characteristics of the lesion are not consistent with a basal or squamous cell carcinoma or a benign nevus (mole).
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by
first intention. Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.
A nurse assesses wound evicsceration in a client that had abdominal surgery. In what position should the nurse place the client?
knees flexed, supine The priority is to return the intestines to the abdominal cavity, and placing the client in the supine position with knees bent will help with this. The Trendelenburg position would allow the intestines to return to the abdominal cavity, but the client may have difficulty breathing. Placing the client in semi-Fowler's position does not allow the return of the intestines, and neither would left lateral Sims.
The nurse reviews the laboratory results for a client with type 2 diabetes who is scheduled for surgery in about one month. What result should the nurse notify the healthcare provider about as most relevant to the preoperative plan of care?
low hematocrit (HCT) and hemoglobin (Hb) levels Low preoperative HCT and Hb levels indicate the client may require a plan for banking of blood (autologous transfusion) or other blood-conservation techniques prior to surgery. Given the procedure is a month away, this means the healthcare team can make plans to offset the risk of anemia related to surgical blood loss. Low urea and creatinine levels are not significant findings, and the neutrophil count of 75% falls within normal parameters. A single elevated random blood glucose result does little to direct care. Rather than focus on this single result, the nurse would examine the glycated hemoglobin level and the client's overall glucose trends to direct preoperative glucose management.
A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy?
maintaining the client's fluid and electrolyte balance After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Although caloric intake is important for healing, it is not the priority. Pain control and emotional support are also a lower priority than physiological needs.
When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which goal?
meeting the child's nutritional needs for optimal growth The goal of care is to prevent intellectual disabilities by adjusting the diet to meet the infant's nutritional needs for optimal growth. The diet needs to be started upon diagnosed, ideally within a few days of birth. Serum phenylalanine level should be maintained between 3 and 7 mg/100 mL (180 to 420 ?mol/L). Significant brain damage usually occurs if the level exceeds 10 to 15 mg/100 mL (600 to 900 ?mol/L). If the level drops below 2 mg/100 mL (120 ?mol/L), the body begins to catabolize its protein stores, causing growth restriction.
A client with Stevens-Johnson syndrome exhibits the following clinical manifestations. Which assessment finding requires priority action by the nurse?
oral temperature of 102.2°F (39°C) Infection and sepsis are life-threatening complications for a client with Stevens-Johnson syndrome. An elevation in the client's temperature is a priority assessment finding and requires immediate action by the nurse. A pain level of 5 on a scale of 1 to 10 is moderate and is not considered life-threatening. A respiratory rate of 16 breaths per minute is within normal limits. Numbness and tingling of the upper extremities need to be assessed further and may be related to another health problem, but it is not considered life-threatening.
The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder?
phenytoin Antiseizure medications are often the cause of toxic epidermal necrolysis. Other common medications that may cause toxic epidermal necrolysis include antibiotics, NSAIDs (nonsteroidal anti-inflammatory drugs), and sulfa medications.
The nurse is using home telehealth monihe nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder?
phenytoin Antiseizure medications are often the cause of toxic epidermal necrolysis. Other common medications that may cause toxic epidermal necrolysis include antibiotics, NSAIDs (nonsteroidal anti-inflammatory drugs), and sulfa medications.
When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by:
proper positioning and moving of the client. Shearing forces occur because of improper movement and positioning, which causes the underlying tissues and capillary blood supply to be pulled and disrupted. This leads to tissue trauma and the potential beginning of skin breakdown. To prevent shearing, clients should be moved with the use of lift sheets and other devices, thus preventing dragging of the skin across the mattress and linens. Clients should also be positioned and supported to prevent pulling or tension of the skin across bony prominences. Turning clients, if not done properly, can cause shearing injuries. Keeping the skin clean, dry, and moisturized is an important aspect of care, but care must be used to decrease the amount of pulling forces exerted on the tissues.
A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:
quantification of T-lymphocytes. Quantification of T-lymphocytes is used to monitor the effectiveness of treatment for HIV. E-rosette immunofluorescence is used to detect viruses in general; it doesn't confirm HIV infection. The ELISA test detects HIV antibody particles but may yield inaccurate results; a positive ELISA result must be confirmed by the Western blot test. The Western blot test — electrophoresis of antibody proteins — detects HIV antibodies when used in conjunction with the ELISA. It isn't specific when used alone and doesn't monitor the effectiveness of treatment.
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation
serum creatinine level of 2.5 mg/dL (221 µmol/L) Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL (35 to 50 g/L).
