PP Unit one integumentary

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."

A female 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 client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?

"Apply sunscreen even on overcast days."

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."

A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?

"If I notice tingling in my lips or mouth, gargling may help the symptoms."

Which is the best nursing response to make when a client asks why there are small lumps under the suture line of the incision three weeks after abdominal surgery?

"Those lumps are caused by new tissue growing at different rates."

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.

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?

Apply direct pressure to the finger with a clean, dry cloth.

A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take?

Assess oxygen saturation using pulse oximetry.

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.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which statements by the nurse are correct about this type of burn? Select all that apply.

B. This is a severe burn and nerve endings have been destroyed D. The child must be monitored for signs of fluid shift. E. Rehabilitation and skin grafting will be necessary.

The nurse reviews a client's lab values and implements which intervention to help with maintenance of skin integrity?

Begin infusion of intravenous fluids.

The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions, which areas have provided effective outcomes in preventing pressure ulcers? Select all that apply.

Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. Turn and reposition the client every 1 to 2 hours unless contraindicated. Use positioning devices to position the client and increase comfort.

The nurse is using home telehealth monitoring to manage care for an 80-year-old client who is homebound. 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. During 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) with the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit with the previous visit, the nurse should do what next?

Contact the health care provider to request a hydrocolloid dressing.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

A client is receiving fluid replacement with lactated Ringer's solution after 40% of the body was burned 10 hours ago. The assessment reveals a temperature of 97.1°F (36.2°C), heart rate of 122 bpm, blood pressure of 84/42 mm Hg, central venous pressure (CVP) of 2 mm Hg, and urine output of 25 mL for the last 2 hours. The intravenous (IV) rate is currently at 375 mL per hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse should request which prescription from the health care provider?

IV rate increase

The nurse is planning care for a group of clients who are at risk for the development of pressure ulcers. What should the nurse do first?

Identify at-risk clients on admission to the health care facility.

The nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do?

Instruct the client to elevate the left leg when sitting in the chair.

The nurse is assessing a client with dark skin for the presence of a stage I pressure injury. Which is the best approach to making this assessment?

Look for skin color that is darker than the surrounding tissue.

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.

Perform range-of-motion exercises. Reposition the client every 2 hours. Encourage the client to eat a well-balanced diet.

The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed.

Which action should the nurse take when providing emergency care at the accident site for a victim with a heat burn?

Pour cool water over the burned area.

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next?

Reposition the client off the reddened skin and reassess in a few hours.

A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted to the emergency department with lesions on the hands. The health care provider prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply.

Take the prescribed antibiotics for 60 days. Expect the skin lesions to clear up within 1 to 2 weeks.

Which statement would be appropriate for a nurse documenting a stage 1 pressure injury found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.

A client with a partial thickness burn injury has had Biobrane applied 2 weeks ago. The Biobrane is now separating from the wound. What nursing intervention is appropriate?

Trim away the Biobrane that has separated from the wound.

The registered nurse (RN) is referred to a client's home when spouses have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority?

Use hot water throughout wash cycle.

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 apply gloves Remove soiled dressing assess drainage

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 injury

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

a urine output consistently above 40 ml/hour (40 mL/hour)

When developing a teaching plan for a client with an infected decubitus ulcer, the nurse should tell the client that which factor is most important for healing?

adequate circulatory status

The nurse is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention?

administering oral tetracycline with milk to a client with cellulitis

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

amount of subcutaneous tissue

Client reports being under a lot of stress recently with the pregnancy Focused assessment reveals painless, dry, rough patches and bumps on the skin primarily the hands, feet, face, neck, and chest. Skin is dry and flaky without plaques, drainage, or swelling. There are no signs of infection. There is facial erythema and some perioral pallor. Blanching of the skin is delayed. Client denies any allergies that may have caused the rash and states they do not have a history of any skin disorders. Client denies having changed any of their detergents, soaps, or creams. They have not changed their routine. They take daily showers; they state they like the water to be very warm and they use regular body soap, no body moisturizers, and they have not been exposed to any type of poison ivy or oak.

atopic dermatitis -Provide education about skin care. -Recommend a topical anti-inflammatory ointment. -infection -Skin integrity

The nurse is assessing a client who experienced second- and third-degree burns of the arms and hands from a kitchen grease fire. After determining that the client did not experience an inhalation injury, which assessment should be completed next?

blood pressure and heart rate

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

Which clients are at an increased risk of developing Kaposi's sarcoma skin lesions? Select all that apply.

client with acquired immunodeficiency syndrome (AIDS) client status post a liver transplant male client of Mediterranean/Jewish ancestry

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

The nurse is preparing information for a community health fair. Which information should the nurse include to promote healthy skin?

drink adequate amount of water

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.

A nurse assesses a client who was admitted to the emergency department with a thermal burn to the right arm and upper chest. Which assessment requires immediate action?

hoarse voice

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarseness of the voice

The nurse should assess a client who is in the emergency phase of burn management for which finding?

hyperkalemia

A school-age client is experiencing severe itching in both hands that is worse at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. Which nursing diagnosis should the nurse use to plan care for this client?

impaired skin integretiry

A client is asking the nurse about receiving the current shingles vaccine (Shingrix). Which factor indicates the client should receive the vaccine? The client:

is over 50 years of age

A nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should

isolate the client's bed linens until the client is no longer infectious.

A nurse assesses wound evisceration in a client that had abdominal surgery. In what position should the nurse place the client?

knees flexed, supine

Which nutritional deficiency may delay wound healing

lack of vitamin C

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

mafenide

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects

melanoma.

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)

Client has irregular menstrual cycles and recent onset of acne and facial hair. Last menses was 3 weeks ago. Client reports always being a large person but is concerned by a recent upward trend in weight, especially in the "stomach" and is upset at self-image. Client reports hair growth started over past year and that they are distressed about weight gain, facial growth, and acne. Client does not want to be pregnant at this time, but is concerned about being able to get pregnant in the future. Lungs clear to auscultation bilaterally. Auscultation of the heart reveals S1, S2. Dorsalis pedis and posterior tibial pulses strong bilaterally. No pedal edema, brisk capillary refill. Abdomen large, soft; bowel sounds heard in all 4 quadrants. Skin warm and oily; skin color appropriate for ethnicity. Dark hair noted on chin, upper lip, and chest; face and upper chest have open and closed comedones, with pustules; no moon-face

polycystic ovary syndrome (PCOS) -Discuss weight loss program -Anticipate an order for estrogen-progestin oral contraceptives. -weight -menses

A client is at risk for developing a pressure injury. The first warning of an impending pressure injury is when the nurse applies pressure and observes which skin color when pressure is released?

reddish

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority?

replacing fluid and electrolytes

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

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

scale

During the emergency (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)

A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation?

small, waxy nodule with pearly borders

The nurse is assessing a hospitalized older adult client for the presence of pressure injuries. The nurse notes that the client has a 1 × 1-inch (3 × 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 injury

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

A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?

to prevent signs of hypovolemic shock and restore circulatio

The rate at which IV fluids are infused is based on the burn client's:

total body weight and BSA burned.

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should monitor hourly which information that will be used to determine the IV infusion rate?

urine output

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 per hour

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