Tissue Integrity

The nurse is providing care for a client who is on bed rest. The nurse can prevent skin breakdown for this client by

Encouraging the client to move around as much as possible

A client was admitted with full-thickness burns two weeks ago. Since admission, the client has lost an average of a pound of weight each day. The nurse expects the client's diet to be adjusted to include:

High-protein drinks

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client?

Inadequate wound healing

What are expected changes that the nurse might identify when assessing the skin of an older adult? Select all that apply.

Increased wrinkles Hyperpigmented patches

A nurse is preparing to change a client's dressing. The nurse recalls that the basis of surgical asepsis that is needed for this procedure is to:

Keep the area free of microorganisms

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves.

When the exposure method of treatment is used for burns, the nurse explains to the client that

Isolation precautions will be required while hospitalized

A health care provider prescribes oral loperamide (Maalox) and intravenous ranitidine (Zantac) for a client with burns and crushing injuries caused by an accident. The client asks how these medications work. The nurse's best response is:

"They limit acidity in the gastrointestinal tract."

A client has been in a coma for two months and is maintained on bed rest. At what angle should the nurse adjust the head of the bed to prevent the effects of shearing force?

30 degrees

A client is diagnosed with psoriasis and the nurse is providing health teaching concerning skin care at home. What recommendation does the nurse include in the teaching?

Apply moisturizing lotion several times a day

A client has a colostomy after surgery for cancer of the colon. What postoperative nursing intervention maximizes skin integrity?

Apply stoma adhesive around the stoma and then attach the appliance

What is the best nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs

A home care nurse is visiting a client who had a below-the-knee amputation. Which client statement indicates to the nurse that further teaching is needed?

At night, I sleep with a pillow under my knees."

A nurse is caring for a client who is receiving radiation therapy. What information about skin care should the nurse include in the teaching plan?

Avoid the application of lotions and powders over the area

A client had a colon resection and formation of a colostomy two days ago. What color does the nurse expect the stoma to be when assessing its viability?

Brick red

A nurse is assessing a client with the diagnosis of scleroderma for signs of calcium deposits in organs, Raynaud phenomenon, esophageal dysfunction, sclerodactyly (scleroderma of the digits), and telangiectasia (vascular lesions formed by dilation of a group of small blood vessels [CREST syndrome]). What clinical indicators should the nurse expect to identify? Select all that apply .

Esophageal reflux; Spider-like hemangiomas; Episodic blanching of the fingers

A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating?

Eat a mechanical soft diet

A client who had an incision and drainage of an oral abscess is to be discharged. For which clinical finding, if it should occur, should the nurse instruct the client to notify the health care provider?

Pain with swelling after one week

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine is at the greatest risk for developing a pressure ulcer?

Sacrum

A nurse is caring for a client with a below the knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

Press the end of the residual limb against a pillow periodically

A client has an above-the-knee amputation because of a gangrenous leg ulcer. To prevent deformities after the second postoperative day the nurse should

Encourage lying in the supine or prone position

A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors?

Listen to the client's fears

A nurse is caring for a client on the second day after an abdominoperineal resection. How does the nurse expect the stoma to appear?

Moist, red, and raised above the skin surface

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to:

Monitor the client's vital signs.

A client with gastroesophageal reflux disease (GERD) receives a prescription for an H 2 receptor antagonist. Which medications are within the classification of an H 2 receptor antagonist? Select all that apply.

Nizatidine (Axid) Ranitidine (Zantac) Famotidine (Pepcid)

The nurse is caring for a client that had a colostomy three days ago. The primary nursing intervention for this client is to:

Observe drainage and the condition of the abdominal incision

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action?

Obtain the client's vital signs

The nurse is providing colostomy care for a client. What should the nurse use to protect the client's skin surrounding the colostomy opening?

Protective Barrier

The nurse is caring for a client that had a hip replacement two days prior. After removing a bedpan from under the client, the nurse recognizes that a priority nursing intervention is to:

Provide perineal care.

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours?

Pulmonary distress

A client is admitted to the hospital for the surgical creation of an ileostomy. What information should the nurse include in the preoperative teaching plan?

Skin irritation at the stoma site can occur easily.

It is appropriate for the nurse to pull up on the client's skin, release it, and determine if the skin returns immediately to its original position to assess for:

Skin turgor

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is:

Sooty

When changing a postoperative client's dressing, the nurse is careful not to introduce microorganisms into the incision. What type of asepsis includes this principle?

Surgical asepsis