tissue integrity

A nurse is preparing to discharge a glance who has an abdominal wound that is heating by secondary intention. which of the following actions is the nurse priority?

schedule a follow-up visit by home health nurse for dressing changes

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document the drainage which of the following?

serosanguinous

A nurse is caring for a client who has states to be pressured ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

serum albumin 3.2 g/dL

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?

silvery, white scales

A nurse is caring for an older adult client who is at risk for skin breakdown. which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

start the client with the diet high in protein

A nurse's developing a teaching plan for a client who has psoriasis. which of the following information should the nurse include in the plan?

use bath oils to soften and soothe the skin

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

used to transfer device to lift the client up in bed

A nurse is caring for an infant who has diaper dermatitis. which of the following actions should the nurse take?

using moisturizer to wipe urine from the skin

The nurses reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

white blood cell count

A nurse is providing teaching to a client who has psoriasis and a new prescription for a topical cortical steroid cream betamethasone valerate. which of the following information should the nurse include in the teaching?

wrapping plastic around the side can increase the medications effectiveness

A nurse is providing teaching about lies to the parents of a school age child had a well child visit. which of the following information should the nurse include in the teaching?

"encourage your child to avoid sharing hats with other children"

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. which of the following nursing fashions are appropriate? select all that apply

-you supposed to keep heels off the bed surface -minimize skin exposure to moisture

A school nurse conducted a screening for pediculosis capitis identify several children who require treatment. which of the following instructions should the nurse give to the children's parents?

coonan washable items in airtight plastic bags

A nurse is associated client who has had staples removed from an abdominal wound post operatively. The nurse knows separation of the wound edges with copious light brown serious drainage. which of the following actions should the nurse perform first?

cover the room with a moist, sterile gauze dressing

A school nurse is assessing a school age child and notices white flags that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders?

pediculosis capitis

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. which of the following interventions should the nurse include in the plan?

reposition the client at least every 2 hours

A nurse is caring for a client who has a stage one pressure ulcer. which of the following dressings should the nurse plan to apply?

transparent dressing

A nurse is spending care for a client who is confined to bed. which of the following actions should the nurse include in the plan?

reposition the client every two hours

A school nurse identifies that a child has particulosis capitis and educates the child's parents about the condition. which of the following statements by the parents indicates an understanding of the teaching?

"all recently used clothing, bedding, and towels must be washed in hot water"

A nursery providing teaching to a client who has widespread psoriasis and a prescription for a phototherapy. The nurse should include which of the following information in the teaching?

"treatment might be interrupted if areas of redness and tenderness develop"

a nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis which of the following findings should the nurse expect?

scaling and redness between the client's toes

A nurse is caring for a plan to his post-operative following abdominal surgery. The nurse discovers a loop of the bowel to an opening and the surgical incision. which of the following actions of the nurse take?

apply more sense of sterile gauze to the site

A nurse is caring for a child who has tinea pedis. The child's parent asked the nurse what these infection is commonly called the nurse should respond with which of the following common names?

athlete's foot

A nurse is preparing to teach a patient how to care for a child who has impetigo contaglosa. which of the following information should the nurse include in the plan of teaching?

Wash clothing in hot water

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

a reddened area over the sacrum

A nurse working on an orthopedic unit is caring for four clients. which of the following clients should the nurse identify as being a greater risk for skin break down?

an older adult who has a hip fracture and is in buck's traction

A nurse is going for a client who has urinary incontinence. which of the following actions should the nurse implement to prevent the development of skin breakdown?

apply a moisture barrier ointment to the client's skin

A school nurse is assessing a child for particulosis capitis. which of the following manifestation should the nurse recognize as an indication of this condition?

firmly attached white particles in the hair

A nurse is caring for a client who has a large lower leg ulcer. which of the following food should the nurse suggest to the client to provide the most protein for wound healing?

grilled salmon

A nurse is developing a teaching plan for a client who has psoriasis. which of the following actions should the nurse include in the plan?

identify effective stress reduction techniques

A nurse is associated client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage three pressure ulcer?

necrotic subcutaneous tissue

A nurse is teaching a client about nutritional requirements necessary to promote world healing. which of the following nutrients should the nurse include in the teaching?

protein

A school nurse is performing a routine health assessment for a school age child. which of the following findings indicates the nurse should investigate further for pediculosis capitis?

pruritis of the scalp