Fundamentals Test 2 prep U Skin Integrity

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? A. Turn him regularly. B. Perform passive range-of-motion (ROM) exercises. C. Encourage fluid intake. D. Message bony prominences.

A.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority for this client after the stockings are applied? A. Elevate the client's legs while out of bed. B. Remove elastic stockings once per day and observe lower extremities. C. Teach the client isotonic leg exercises. D. Order a second pair of stockings to be rotated each day.

B.

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report? A. swelling around the incision B. redness around the incision C. elevated temperature D. purulent wound drainage

C.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? A. Laterally, from one side of the wound to the opposite side B. From the superior portion of the wound to the inferior C. In a widening circle around the drain, outward from the center D. Laterally, from the distal area to the center

C.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: A. institute range-of-motion (ROM) exercise every 4 hours. B. massage the abdomen once a shift. C. use an alternating air pressure mattress. D. elevate the lower extremities.

C.

What is the primary goal of nursing care during the emergent phase after a burn injury? A. Replace lost fluids. B. Prevent infection. C. Control pain. D. Promote wound healing.

A.

When teaching the diabetic client about foot care, the nurse should instruct the client to: A. avoid going barefoot. B. buy shoes a half size larger. C. cut toenails at angles. D. use heating pads for sore feet.

A.

An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. A. Apply lanolin or petroleum jelly to intact skin. B. Encourage a reduced-calorie, reduced-fat diet. C. Inspect the involved areas daily for new ulcerations. D. Limit activities of daily living (ADLs). E. Use an electric razor to shave.

A. B. C. E.

A nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification? A. Approximated wound edges B. Yellow, purulent drainage C. Sutures in place D. Pink granulation tissue

B.

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child: A. fears another procedure. B. does not understand body integrity. C. is expressing pain. D. is attempting to regain control.

B.

Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to: A. altered balance. B. altered protective pressure sensation. C. impaired hearing ability. D. impaired visual acuity.

B.

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first: A. notify the health care provider. B. mark the area of drainage. C. change the dressing. D. reinforce the dressing.

B.

The nurse evaluates that the client correctly understands how to report signs and symptoms of bleeding when the client says: A. "Petechiae are large, red skin bruises." B. "Ecchymoses are large, purple skin bruises." C. "Purpura is an open cut on the skin." D. "Abrasions are small pinpoint red dots on the skin."

B.

Which nutritional deficiency may delay wound healing? A. Lack of vitamin D B. Lack of vitamin C C. Lack of vitamin E D. Lack of calcium

B.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do? A. Administer pain medication. B. Ensure fluid intake of 3,000 ml per 24 hours. C. Turn the client every 1 to 2 hours. D. Maintain hygiene.

C.

A nurse is assessing an immobile client and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to: A. apply a moist-to-moist dressing, being careful to pack just the wound bed. B. consult with a wound-ostomy-continence nurse specialist. C. reposition the client off the reddened skin and reassess in a few hours. D. complete and document a Braden skin breakdown risk score for the client.

C.

The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema? A. Ambulate every shift while awake. B. Apply lotion on opposing skin surfaces. C. Apply powder to skinfolds. D. Separate opposing skin surfaces with soft cloth.

D.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? A. Avoiding using deodorant soap on the irradiated areas B. Applying talcum powder to the irradiated areas daily after bathing C. Wearing a lead apron during direct contact with the client D. Removing thoracic skin markings after each radiation treatment

A.

What intervention should the nurse include in the plan of care for a child with a fracture in skeletal traction to prevent osteomyelitis? A. Encourage the child to eat nutritious foods. B. Administer prophylactic antibiotics as prescribed. C. Maintain the child in reverse isolation. D. Protect the child from visitors with colds.

A.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? A. "The client is receiving physical therapy twice per day, so he doesn't need a continuous passive motion device." B. "The continuous passive motion device can decrease the development of adhesions." C. "Bleeding is a complication associated with the continuous passive motion device." D. "Monitoring skin integrity is important while the continuous passive motion device is in place."

A.

A client has had a cast applied to the arm. When discharging the client, the nurse should tell the client to: A. use powder on the skin around the cast. B. smell the cast for foul odors. C. use a padded ruler to reach inside and rub under the cast. D. apply a heating pad to the arm for 24 hours after the injury.

B.

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to: A. prevent neurologic damage. B. realign fracture fragments. C. control internal bleeding. D. maintain skin integrity.

B.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: A. provide access for wound irrigation. B. promote drainage of wound exudates. C. minimize development of scar tissue. D. decrease postoperative discomfort.

B.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? A. Press the emergency alarm to call the resuscitation team. B. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. C. Have all visitors and family leave the room. D. Call the surgeon to come to the client's room immediately.

B.

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply. A. Avoid lotions containing calamine. B. Add baking soda to the water in a tub bath. C. Keep nails short and clean. D. Rub the skin when it itches with knuckles instead of nails. E. Massage skin with alcohol. F. Increase sodium intake in diet.

B. C. D.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated? A. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. B. Increase the IV flow rate to offset fluids lost through the therapy. C. Apply a topical antibiotic cream to burns to prevent infection. D. Administer pain medication 30 minutes before therapy to help manage pain.

D.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include? A. Administer aspirin daily as ordered. B. Provide mouth care every 4 hours with lemon-glycerin swabs. C. Administer meperidine (Demerol) I.M. as needed for pain. D. Place a pressure-reducing mattress on the client's bed.

D.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? A. Draw a circle around the moist spot and note the date and time. B. Notify the physician. C. Remove the catheter, check for catheter integrity, and send the tip for culture. D. Remove the dressing, clean the site, and apply a new dressing.

D.

Which is the most appropriate nursing intervention for a client with pruritus caused by medications used to treat cancer? A. administration of antihistamines B. steroids C. Silk sheets D. Medicated cool baths

D.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? A. Bathe daily. B. Eat a high-carbohydrate diet. C. Shift your weight every 15 minutes. D. Move from the bed to the wheelchair every 2 hours.

C.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? A. a 6-year-old with a simple fracture of the femur B. a 42-year-old with a recent, uncomplicated appendectomy C. an 86-year-old with burns from using a heating pad D. an 18-year-old with diabetes mellitus

C.

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele? A. Apply thin layers of tincture of benzoin around the defect. B. Position the neonate on the side. C. Cover the defect with moist, sterile saline dressings. D. Leave the defect exposed to air.

C.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? A. Applying a heating pad B. Debriding the wound three times per day C. Using sterile technique during the dressing change D. Cleaning the wound with a povidone-iodine solution

C.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? A. The tissue surrounding the wound is red and hot. B. The wound drainage is serous. C. The skin around the wound is edematous. D. The granulation tissue is at the wound edges.

D.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Reposition the client every 2 hours. b. Perform range-of-motion exercises. C. Use commercial soaps to keep the skin dry. D. Tuck bed covers tightly into the foot of the bed. E. Encourage the client to eat a well-balanced diet.

A. B. E.

A nurse is performing a baseline assessment of a client's skin risk assessment. Which finding will most impact the goal of the plan of care? A. Family history of pressure ulcers B. Presence of pressure ulcers on the client C. Potential areas of pressure ulcer development D. Overall potential of developing pressure ulcers

D.

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (footdrop) for a client on complete bed rest. The UAP should: A. place a bed cradle at the foot of the bed. B. massage lotion onto the feet daily. C. encourage active range of motion to unaffected extremities. D. place a trochanter roll along the side of the ankle.

C.

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply. A. nutrition and hydration needs B. capillary refill C. continued need for restraints D. need for medication E. skin integrity

A. B. C. E.

A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task? A. Keep the side rails up. B. Position the overbed table away from the bed. C. Raise the bed to approximately waist level. D. Position the client on the far side of the bed.

C.

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? A. Instilling eye drops B. Nasogastric tube irrigation C. I.V. catheter insertion D. Colostomy irrigation

C.