Integumentary ATI and Evolve

A nurse is caring for a client who has deep partial and full thickness burns and requires a topical antimicrobial drug. The goal of this medication therapy is to reduce which of the following outcomes?

Bacterial growth rationale: topical antimicrobial medication (particularly broad spectrum antimicrobials) help prevent bacteria from entering the body when a client has impairment of the protective covering of the skin like burns. This medication creates a protective barrier, along with the dressing, between bacteria and the exposed body tissues to help prevent infection.

Most susceptible places for pressure injury are

Bony prominences: heels, toes, sacrum, hips, elbows, shoulders and back of head

A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of a malignant melanoma?

Irregularly shaped with blue tones. rationale: irregularly shaped with blue, red, or white in tone. The often occur on a clients upper back and lower legs.

A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicate that she has adapted to her changed body image?

May I go with my family to the visitors lounge? rationale: statement demonstrates a positive self image

A nurse is caring for a client who has a lesion on the back of his right hand. The client asks the nurse which type of skin cancer is the most serious. Which of the following responses should the nurse make?

Melanomas rationale: melanomas are malignant neoplasm with atypical melanocytes in the epidermis the dermis and sometimes the subcutaneous cells. It is the MOST lethal type of skin cancer, often causing metastases to the bone, liver, lungs, spleen and the CNS and lymph nodes.

A nurse is reinforcing teaching with the guardian of a child who has contact dermatitis. Which of the following information should the nurse include?

Place the child in a bath with colloidal oatmeal. this helps relieve the childs itching

A nurse is caring for a client who has suspected fungal skin lesion. Which of the following labs findings should the nurse expect to review to confirm the diagnosis?

Potassium hydroxide - reveals if skin lesions are fungal in origin

Stage 2 pressure injury: partial thickness skin loss

Presents partial thickness skin loss, with pink or red viable tissue in the wound bed. The tissue is moist, and deeper tissue not visible.

A nurse is reinforcing discharge teaching with a client who is post op following surgical excision of a basal cell carcinoma. Which of the following findings should the nurse include as an indication of malignancy of a mole?

Ulceration rationale: Ulceration, bleeding or exudation are indications of a mole potential malignancy. The increasing size is also a warning sign. The nurse should emphasize the importance of lifetime follow up evaluations and review the proper techniques for self examine the skin every month.

A nurse is reinforcing teaching with a client who has a large wound healing by secondary intention. The nurse should instruct the client that which of the following nutrients promotes wound healing?

Vitamin C rationale: a diet high in protein and vitamin c is recommended because these nutrients promote wound healing

A nurse is collecting data from a client who has sustained deep partial thickness and full thickness burns over 40% of the body 24hours ago. Which of the following are findings ate common during this phase?

-Temperature 36.1 (97)- happens because the bodies ability to regulate temperature is compromised -Hyperkalemia-occurs from leakage of fluid from the intracellular space -Hyponatremia-occurs during the initial phase of burn as result in sodium retention in the interstitial space

Good nursing care includes protection of the skin and prevention of skin tears. Which are the categories of skin tears based on the Payne-Martin classification system? (Select all that apply

- A skin tear without tissue loss and the edges can be realigned -A skin tear with partial tissue loss and the edges cannot be realigned -A skin tear with complete tissue loss in which the epidermal flap is missing rationale: Skin tears based on the Payne-Martin classification system include a skin tear without tissue loss and the edges can be realigned, a skin tear with partial tissue loss and the edges cannot be realigned, and a skin tear with complete tissue loss in which the epidermal flap is missing. A tear with deep tissue and/or muscle exposure is not considered a skin tear and is not among the skin tears based on Payne-Martin classification system.

A nurse is assisting with the development of an education session about malignant melanoma for a group of clients. The nurse should include that which of the following clients has increased risk of developing malignant melanoma?

A client who has light complexion rationale: light complexion and less pigmentation place a client at increased risk of malignant melanoma.

Circular portable wound suction device

A drain in which the drainage tube is attached to a container with a spring inside. The spring expands as the container draws fluid out of the wound.

Bottle drain

A silicone drain with bottle that is used when the amount of drainage is expected to be large

A nurse in an urgent care clinic is caring for a client who has snakebite on her arm. Which of the following actions should the nurse take?

Immobilize the limb at the level of the heart rationale: the emergency management of a client who has snakebite involves limiting the spread of venom. Any constrictive clothing or jewelry should be removed before swelling worsens, and the affected limb should be immobilized at the level of the heart.

A nurse is caring for a client who has sustained burns over 35% of total body surface area. The clients voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?

Inhalation injury wheezing and hoarseness indicate inhalation injury with impending loss of the airway.

A nurse is reinforcing teaching to a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include

Apply topical medication for up to 2 weeks after the fungal lesions are gone-applied 1 to 2 weeks

Stage 4 injury: full thickness skin and tissue loss

Characterized by full thickness tissue loss. The fascia, muscles, tendons, ligaments, cartilage, and or bone are visible. Edges are rolled, undermining and funneling may be present. Dead tissue may also be seen

A nurse is caring for a client who is 7 days post op following abdominal surgery. The clients reports nausea, vomiting, and pain at the inaction site. The nurse observed serosanguineous discharge on gown, and the abdominal incision is partially open.

Dehiscence

A nurse is assisting with planning care for a client who has deep partial thickness and full thickness thermal burns over 40% of his total body surface. The client is in acute phase of burn injury. Which of the following interventions should the nurse include in the plan?

Initiate range of motion exercises. rationale: the nurse should begin performing active and passive range of motion exercises with the client to maintain mobility and prevent contractures.

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the clients questions about the dressing, the nurse explains that it is obtained from which of the following sources?

Pig skin rationale: heterografts are obtained from an animal, usually a pig

A nurse is reinforcing teaching with a client who is wheelchair bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include?

Shift your weight in the wheelchair every 15 minutes. rationale: this response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure.

A nurse is assisting with the care of client who is resuscitation phase following a major burn. Which of the following labs finding should the nurse expect?

Sodium 132 mEq/L rationale: to have a low sodium level because sodium is trapped in interstitial space

A nurse in a providers office is collecting data from a client who has severe sunburn. Which of the following classification should the nurse use to document this burn?

Superficial thickness superficial thickness damages the top layer of skin

A nurse is observing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. the nurse should classify this injury as which of the following?

Third degree frostbite. rationale: when client has frostbite the skin of the affected area has small blisters that are blood filled and the skin does not blanch.

Nutrients that promote wound healing

Turkey(protein), salmon(omega 3) orange(vitamin c) shellfish(zinc) broccoli(vitamin a)

A patient is to have a culture and sensitivity test. Which education should the nurse provide to the patient regarding a culture and sensitivity test?

a sample of exudate is taken from the lesion. rationale: When a bacterial, viral, or fungal infection of the skin is suspected, the dermatologist may wish to know the causative organism and the drug most appropriate for treating the specific infection. A sampling of exudate (drainage) is taken from the lesion and sent to the laboratory for culturing. Once the organism has been cultured, colonies can be tested for sensitivity to certain antiinfective agents. These tests take the guesswork out of treating infectious skin disease and very quickly determine which drug will be most effective in treating it. A biopsy requires removal of a sample of tissue.

A nurse is caring for a client who has contact dermatitis and has new prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor?

anorexia-adverse effect of diphenhydramine

A community health nurse is reinforcing teaching about melanoma with a group of clients. Which of the following characteristics of lesions associated with melanoma should the nurse include in the teaching?

irregular border rationale: the nurse should identify that skin cancer lesions, including melanoma, are expected to exhibit border irregularity. The nurse should reinforce teaching with clients about the appearance of melanoma lesions including asymmetry of shape, irregularity, color variation with a single lesion, diameter greater than 6 mm and evolving or changing any feature.

The nurse is providing education to a group of teenage girls on the importance of wearing skin protection when outside. The nurse should inform the girls that overexposure to ultraviolet (UV) rays can cause which change in the skin?

severe wrinkles rationale: Overexposure to the UV rays of the sun can seriously and permanently damage the superficial and deeper layers of the skin. The damage results in severe wrinkling and furrowing, as well as loss of elasticity, and the skin assumes a tissue-paper transparency. In addition to the potential for premature aging and degenerative changes, solar damage can also result in malignant changes. UV overexposure does not cause skin thinning, loss of hair follicles, or loss of adipose tissue.

The nurse is caring for a patient with a skin tear. Which dressing is most appropriate to apply to the area?

silicone coated net dressing rationale:If bleeding has stopped, silicone-coated net dressings are preferred; petroleum-based protective ointments are also used to provide protection for a skin tear and keep the wound bed moist to promote healing. A moist sterile gauze is used for a deeper or infected wound. Hydrocolloid is used for deeper pressure ulcers. Paste is used to fill in a deep wound

During the change-of-shift report, the nurse notes the patient has several papular lesions. The oncoming nurse will most likely observe which lesion?

small, solid elevation of the skin. rationale: A papule is an elevated, solid lesion that is less than 0.5 cm in diameter. Examples of papules include warts (verruca) and elevated moles.

When a patient with burns has a full-thickness wound, which of these tissues are involved?

the entire dermis and subcutaneous tissue rationale: A method to evaluate the depth of burns is based on the layers of skin that have been damaged. Full-thickness wounds involve all layers of skin and the destruction of the epidermal appendages. Wounds of this type will require grafting for the wound to heal and for optimal function to be restored. Partial-thickness wounds are those in which the epidermal appendages (sweat and oil glands and hair follicles) are not destroyed; these wounds will heal by themselves if no further injury occurs from either infection or inappropriate treatment for the phases of wound healing. Grafting may or may not be necessary.

A nurse is reviewing information about a new prescription for corticosteroid cream with a client who has mild psoriasis. Which of the following instructions should the nurse include?

-Apply an occlusive dressing after application -wear gloves after application to lesions on the hands -avoid applying in skin folds

A nurse is providing education about pressure injury development to a newly licensed nurse. Which of the following points should the nurse include in the teaching?

-Shear forces occur when the skin and muscles are pulled in opposite directions -Pressure injuries most often develop over bony prominences -Factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss

A nurse is contributing to the plan of care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

-limit visitors in the client's room-decrease risk of infection -increase protein intake-promotes wound healing -restrict fresh flowers in the room- flowers carry bacteria can increase the risk for infection

ABCDE method of screening for skin cancer

A- asymmetric shape B-border irregularity C color variation within a lesion D-Diameter >6mm E-evolving or changing in any feature of lesion

A nurse in providers office is caring for a client who has new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?

Acyclovir rationale: is antiviral medication that inhibits replication of the virus that causes herpes zoster.

A nurse is caring for a client who has herpes zoster. Which of the following medications should the nurse expect to administer for treatment?

Acyclovir - medication use to treat herpes

A nurse is reinforcing teaching with a client who has history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include?

Administer a psoralen medication before treatment.

portable wound suction device

An active closed system drain that uses negative suction to drain fluid from the wound it contains a flexible plastic bulb that is connected to a plastic drainage tube.

A nurse is caring for a client who has regular occupation exposure to sunlight and presents to the clinic for evaluation of several lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma?

An irregular shaped brown lesion with light blue areas on the neck

Penrose drain

An open drain made of corrugated rubber that is kept outside of the wound by attaching it with a safety pen

A nurse is reinforcing teaching with a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include?

Apply warm compresses to the affected area-promotes comfort

A nurse is assisting with the development of a program to educate clients about measures to reduce the risk of skin cancer. Which of the following instructions should the nurse include?

Avoid exposure to the midday sun. rationale: the nurse should instruct clients to avoid skin exposure to the sun between 1100-1500 when sun rays are the strongest.

A nurse is reinforcing teaching with a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues?

Epidermis rationale: basal cell carcinoma originates from the epidermal layer of the skin. It is the MOST common form of skin cancer.

A nurse is screening a client for skin cancer. When reinforcing teaching with the client about skin cancer risk, which of the following risk factors should the nurse include?

Excessive exposure to ultraviolet light. rationale: sunlight or tanning beds, occupational exposure, carcinogens and chronic skin irrational are risk factors for skin cancer.

Stage 3 pressure injury: full thickness skin loss

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue or new skin tissue that forms on the surface of the wound, is often present and wound edges may be rolled. Dead tissue may have formed. Undermining and tunneling may also be present. The fascia, muscles, tendons, bone, ligament, and cartilage are not visible in this stage

A nurse is collecting a wound culture from a clients arm wound. The nurse explains to the client the reason for needing to rinse the wound with 0.9 sodium chloride during the procedure. Which of the following statements should the nurse include

I am rinsing the wound to prevent your normal skin micro organisms from contaminating the culture.

A nurse is assisting with the admission of a client who is bedridden and was admitted from home. The nurse notes a shallow crater in the epidermis of the clients sacral area. The nurse should document that the client has pressure ulcer at which of the following stages?

Stage II. rationale: there is partial thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and can appear as abrasion, blister, or shallow crater. Edema persists, the ulcer can become infected. The client might report pain, and there might be a small amount of drainage.

A nurse is contributing to the plan of care for a client who has been admitted for the treatment of malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures?

Surgical excision rationale: the therapeutic approach to malignant melanoma depends on the level of invasion and the depth of lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide, local excision followed by skin grafting.

A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention?

Surgical incision rationale: with primary intention, a clean wound is closed mechanically, leaving well approximated edges, and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.

Braden score

The lower the overall score the client received the greater risk the client has for alterations in skin and tissue integrity

A 56-year-old patient is admitted to the hospital with pneumonia and shingles. The nurse is aware that shingles is caused by which occurrence?

activation of varicella zoster in individuals who have had varicella rationale: Shingles is an activation of the chickenpox virus in an adult. Although related to it, the herpes simplex virus does not cause chickenpox or shingles. Herpes simplex II does not cause chickenpox or shingles. A compromised immune system (such as might occur when a patient has pneumonia or another infection, the immune system is fighting) does predispose an individual to opportunistic viruses, such as herpes zoster and herpes simplex, however.

The nurse is providing education to a patient recently prescribed a topical medication. Which instruction would be appropriate for the nurse to give the patient?

apply medication directly to the surface of the affected area rationale: Topical treatments involve the application of compounds directly to the skin and are not mixed into a patient's bath water. Oral medications are ingested by mouth. Subcutaneous or intradermal medications are injected into the lesion.

The nurse is reviewing the chart of an African American patient and reads that the patient presented to the emergency department with pallor. Pallor is a term used to describe which assessment?

ashen gray tone to the skin rationale: Pallor in a dark-skinned person presents as an ashen-gray tone to the skin. In a brown-skinned person, pallor gives the skin a yellow-brown color. An extremely pale color to the skin is pallor in a white-skinned person. Inflammation appears as redness, usually accompanied by increased warmth. Bruising is referred to as ecchymosis.

A patient who is recovering from a severe burn is permitted oral feedings. Which diet is most appropriate for this patient?

high in protein and high in calories rationale: A diet high in protein and calories is necessary for healing. The patient has increased metabolic needs directly proportional to the size of the burn area. Nutritional needs may be increased 50% to 150% above normal, and increased requirements can continue for 9 to 12 months. Caloric needs are calculated to include the patient's weight, age, and percentage of burn over total body surface.

A nurse is reinforcing teaching with a client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following lab values should the nurse monitor?

hypercalcemia- is possible adverse effect of calcipotriene

A nurse is caring for a client who has been apply silver sulfadiazine cream to a deep partial thickness arm burn for the past two weeks. The nurse should monitor the client for which of the following adverse effects?

leukopenia rationale: the nurse should monitor the client for an allergic reaction that is causing decrease in the clients WBC count

A patient's burns have become infected with Pseudomonas. The nurse should anticipate using which topical dressing?

mafenide acetate rationale: Mafenide acetate is effective against a Pseudomonas infection. The patient should also receive pain medication before dressing changes; this medication produces a burning sensation when applied to wounds. Silver nitrate, silver sulfadiazine, and povidone-iodine are not the best options for a Pseudomonas infection.

The nurse is caring for a patient who has been admitted to the acute care facility with painful, infected lesions of the skin. Which action would be the priority of the LPN/LVN?

observing and carefully recording the patients skin condition. rationale: The first priority is for the nurse to observe the area and document the findings. There is no indication of the type of skin lesions present. Cleaning the affected area with soap and water, disinfecting the lesions by giving the patient a tub bath, or applying lotion must be undertaken only after orders are received from the primary health care provider. Initiating these types of interventions would be against the scope of practice.

The nurse is preparing to care for a patient with psoriasis. The nurse should anticipate which skin assessment?

patches covered with silvery scales rationale: Psoriasis is a noncontagious, chronic, and recurring skin disorder that typically appears as inflamed, edematous skin lesions covered with adherent silvery-white scales. These scales are the result of an abnormally rapid rate of proliferation of skin cells. Zigzag lesions, fluid-filled blisters, or an area of local swelling and redness are not anticipated assessment data in a patient with psoriasis.

In the immediate care provided to a burn victim with second- and third-degree burns of the arms and legs, the LPN/LVN should expect the primary health care provider to order which intervention?

replacement of lost fluids and electrolytes rationale: A priority concern in the patient who has experienced severe burns is the prevention of shock. The two most important measures to relieve profound shock are replacement of lost fluids and electrolytes (fluid resuscitation) and enhancement of tissue perfusion. Antibiotic use may be included in the plan of care but is not of greater priority than the prevention of shock. The patient may be medicated for pain and anxiety, but it is not the priority action. Occlusive dressings are not the appropriate option for this patient.

When a patient has herpes zoster (shingles), the LPN/LVN should expect the patient to report which symptom?

severe pain rationale: Shingles begins with vague symptoms of fatigue and low-grade fever and possibly loss of appetite. There may be only aching or discomfort along the nerve pathway with or without erythema. About 3 to 5 days after onset, small groups of vesicles appear on the skin. They are usually found on the trunk and spread halfway around the body, following the nerve pathways leading from the spinal nerve to the skin. Rash on the extremities and respiratory involvement are not expected.

The nurse is caring for a patient with an electrical burn. What should be monitored on this patient?

the heart rationale: Electrical burns damage tissue deep within the body. The extent of damage is not always visible and the entrance site and exit site may appear small. Cardiac monitoring should be initiated even if the patient does not complain of chest pain. The lungs, kidneys, and gastric mucosa should be monitored with other types of burns.

A patient asks the nurse about the expected changes that occur in the aging skin. What are some appropriate responses by the nurse? (Select all that apply.)

-skin is much slower to heal -the skin may become more dry and itchy -the skin becomes more wrinkled and saggy -the skin is at increased risk for becoming sunburned rationale:The appropriate responses regarding expected changes that occur as the skin ages are that the skin becomes thinner, much slower to heal, more dry and itchy, wrinkled and saggy, and is at increased risk for becoming sunburned.

The patient presents to the clinic with severe dermatitis that is refractory to avoidance of irritants, maintenance of skin moisture, and skin lubrication. The nurse anticipates which treatments will be prescribed? (Select all that apply.

-skin lubrication -topical hydrocortisone rationale: In general, treatment of dermatitis is aimed at avoidance of the contact irritant or allergen, good skin lubrication, preservation of skin moisture, and control of inflammation and itching. Topical agents are often used. Corticosteroids may be used topically, or sometimes orally or by injection to intervene in a severe episode of dermatitis. Tretinoin, salicylic acid, and frequent exfoliation are drying and irritating to the skin and would worsen the patient's symptoms.

A nurse is teaching a group of older adults at a community center about functions of the skin. Which of the following states should the nurse include?

-skin plays importent role in the production if vitamin D. -the skin protrctd against bacteria and viruses. -the skin helps regulate the body temperature.

The patient has been diagnosed with acne rosacea. The nurse should educate the patient to avoid which substances? (Select all that apply.)

-tea -beer -wine -coffee rationale: Caffeine-containing drinks (e.g., tea and coffee) and foods, alcoholic drinks (including beer and wine), and spicy foods cause flare-ups of rosacea. Milk and juice do not cause rosacea flare-up.

A nurse in a dermatology clinic is using the ABCDE method while screening several of a clients skin lesions for skin cancer. Which of the following findings should the nurse report to the provider?

Color variation within a lesion. rationale: The C in the ABCDE method of screening for skin cancer stands for color variation within a lesion. The E stands for evolving or changing in any feature of lesion.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

A nurse is reinforcing discharge instructions to a client who had skin biopsy with sutures. The nurse should identify that which of the following client statements indicated understand?

I should apply antibiotics ointment to the area

A nurse is reinforcing teaching with a client who has burn injuries to his trunk about what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching

I will be on a special table rationale: by using showering technique as opposed to a tub bath the water can be kept at a constant temperature, and there is a lower risk of wound infection

A nurse is assisting with the care of a client who sustained deep partial thickness and full thickness burns over 60% of their body 24 hours ago and is requesting pain medication. The nurse should ensure the medication is administered using which if the following routes to administer the medication?

Intravenous-rapid absorption and fast pain relief during the resuscitation phase.

Would culture collection

Label culture tube Remove old dressing Rinse wound with 0.9 sodium chloride Remove swab from culture tube Place sterile swab into the wound bed Rotate the swab stick in an area of drainage Activate the culture medium Note if the client has received any recent antibacterial or anti fungal therapy

A nurse is caring for a client who has smoke inhalation and full thickness burns covering 63% of her body. Which of the following nursing actions is the nurses PRIORITY?

Monitor respiratory status rationale: ABC

A nurse in a provider office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5cm in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions?

Papules rationale: A papule is a small, solid, elevated lesion with distinct borders. It is usually <10 mm diameter. Warts and elevated moles are examples of papules.

A nurse in a urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect FIRST?

Respiratory rate rationale: Should apply ABC priority setting framework

A nurse is collecting data from a client who sustained superficial partial thickness and deep partial thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Temperature of 39.1 (102.4) rationale: Elevated temp is indication of infection, and the nurse should report this finding to the provider.

A nurse is reinforcing discharge teaching about foot care with a client who has diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

Test water temperature with the wrist. rationale: clients who have diabetes have peripheral nerve damage, making it difficult to determine temperature and increasing the risk of burns.

A nurse is collecting data from a client who is three days post op following abdominal surgery. The clients incision is slightly edematous, appears pink with crusting on the edges, and is draining serosanguinous fluid. Which of the following statements describes the incision?

The incision is showing signs of healing without complications. rationale: consistent with appropriate healing without complications

Stage 1 pressure injury: non blanchable erythema

The skin is intact with a localized area of non blanchable erythema. Sensation, temp and changes in consistency of the skin and tissues may precede color changes.

Which instruction should be included when providing health teaching about exposure to the sun?

Use sunscreen even on cloudy days if you expect to be outdoors for extended periods of time. rationale: Sun exposure and subsequent damage can happen on both sunny and overcast days. Experts agree that there is no such thing as a "good tan." The hours between 11 A.M. and 3 P.M. are those in which the rays of the sun are the strongest and most damaging to the skin. Darker-skinned individuals may also experience burns and damage from overexposure to the sun's rays.