RN Alterations in tissue Integrity
A nurse is providing education regarding burn prevention to a community group. which of the following causes should the nurse identify as a leading cause of adult burns?
Flames 🔥
A nurse is caring for a client with 38% of the body surface area (BSA) burned. Which of the following will be optimal for fluid volume replacement?
IV crystalloids
A nursing supervisor is determining the workload for nurses caring for clients w/altered skin integrity. Which of the following addresses the concern for cognitive load of the nursing staff?
Managing the nurses stress to optimize decision making
A nurse is caring for a client who has atopic dermatitis. The client Asia's what has caused this rash. Which of the following is an appropriate way for the nurse to respond?
"This cause is unknown but may be caused by by the immune system"
A nurse is caring for a client who has experienced burns. Which actions should the nurse anticipate? Select all that apply?
-2 large bore peripheral IV's -monitor for extremity of perfusion -place a urinary catheter
A nurse is caring for a client who has sustained a 40% TBSA burn. The client states that their life is over, and they do not want to go undergo the surgeries for their wounds to heal. Which statement would be most appropriate response from the nurse?
"Can you tell me more about your life being over?"
A nurse is taking care of a client who has a new diagnosis of eczema. The client asks the nurse about what could be causing it. Which of the following statements by the nurse be the most appropriate?
"It may be caused by genetic, immune, or environmental causes"
A nurse is caring for a client who is schedules to have a NPWT. The client asks why this type of therapy would be needed on the wound. Which of the following is the nurses best response?
"NPWT removes moisture and helps new skin cells to fill in the wound"
A nurse is reviewing the intake and output of the client and notes an intake of 600 ml of fluids more than the recorded output of fluids. The nurse asks the charge nurse if this would warrant a call to the provider. Which of the following responses from the charge nurse would be the most appropriate?
"No, we should not call the provider because the difference in intake and output is likely related to insensible fluid loss."
A nurse is caring for a client who exhibits skin inflammation. Select the 4 findings that indicate anaphylaxis & require immediate following?
-hives -low BP -throat tightness -GI upset
A nurse is assessing a client who has sustained a superficial skin injury that has disrupted the epidermis. Which of the following is a function of the epidermis? Select all that apply
-prevents fluids from going in -contains normal flora -influences skin color
A nurse is creating a teaching plan for a client to self manage their wound. Which of the following should the nurse consider in the plan of care? Select all that apply
-the clients preferred learning style -the barriers to the clients ability to learn -inviting a family member or caregiver to the teaching
A nurse is caring for a client who has burns. The order set calls for the use of the Parkland formula to calculate fluid replacement. Which of the following best describes the Parkland formula?
2 to 4 ml x kg x % TBSA burned
A nurse is caring for a client who weighs 60kg, w/a 38% total body surface (TBSA) burn. According to the fluid calculation method of Rule of 10's, which of the following would be the appropriate fluid volume replacement?
400 ml/hr
A nurse is caring for 4 clients on a medial surgical unit. Which of these clients is most susceptible to a moisture-related skin injury?
A client who has incontinence
A nurse is caring for 4 clients. Which of the following clients would be the most likely to sustain a pressure injury?
A client who has reduced mobility from spinal cord injury
A nurse is caring for a group of clients. Which of the following clients is most susceptible to keloid scar formation?
A client who is black
A nurse is caring for a group of clients and is concerned about the skin injury. Which of the following clients would be at risk for a friction- related skin injury?
A client who requires assistance to move up in bed
A nurse is airing for a client who has fever. Vasodialation of the skin provides which of the following physiological changes?
Allows heat to escape the skin, reducing temperature
A nurse is assessing a group of clients. Which of the following clients is most susceptible to skin tear?
An 80 yr old client who takes steroid medications
A nurse is assessing a clients sensory level and determines that the client has sensory changes on the top of the shoulder. Which of the following dermatome levels associated with the sensory deficit?
C-4
A nurse is assessing clients for skin problems on the medical surgical floor. Which option is most likely to result in chronic wounds?
Diabetic foot ulcer
A nurse is taking care of a client who has a new skin condition. Which of the following should the nurse recognize as a herpes simplex condition?
Painful sores clustered on one side of the mouth
A nurse is caring for a client who has scabies in a home setting. Which of the following is a nursing consideration in providing nursing care?
Preventing the spread of the condition
A nurse is assessing a clients skin & notes redness, scaling, inflamed skin in the knee area. Which of the following skin conditions could this possibly be?
Psoriasis
A nurse is caring for a client who demonstrates an inflammatory skin condition. For each manifestations, click to specify the assessment findings is consistent w/ psoriasis, atopic dermatitis, Steven Johnson Syndrome.
Psoriasis -dry skin, scaly patches, itchy skin Atopic Dermatitis -dry skin, itchy skin, Steven Johnson Syndrome -bright red macules & papules, skin sloughing, involvement of mucous membranes
A nurse is caring for a group of clients. Which of the following will have the most significant impact on the psychological well-being of the client?
The severity of the wound
A nurse is caring for a client who has delayed wound healing. Which of the following is a priority for the nurse and health care team to address to optimize would healing?
The wound has purulent drainage & foul smell
A nurse is caring for a client who had surgery a month ago, and is now being seen in the clinic for excessive wound healing. Which of the following options should the nurse identify as the problem
There is a scar formation beyond what is normally expected
A nurse is caring for a client who has chronic wound. Which of the following is the purpose of the BPA test?
To measure pathogenic bacteria in the wound
A nurse educating a client on home care for a wound. What should the nurse do to ensure the client understands the teaching
Utilize a teach back method for the client to show the nurse what should be done
A nurse is caring for a client who has a wound. Which of the following actions can the nurse take to promote their own safety?
Utilize appropriate standard precautions or isolation procedures
A nurse is evaluating a wound and describes it as a 4mm punched out area of the lower extremity. Which of the following is most likely the cause of the wound?
arterial insufficiency
