mdsrg ati REVIEW SKIN

A nurse is assisting with the admission of a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions be added to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B

A nurse is assisting with the care of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL

B

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 an increased risk of developing malignant melanoma? A. A client who has brown eyes B. A client who has a light complexion C. A client who has black hair D. A client who is 20 years of age

B

A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? A. Administer pancrelipase to the child prior to each meal B. Supplement the child's feedings with enteral feedings C. Provide the child with a low-protein meal D. Perform dressing changes 10 minutes prior to the child's meals

B

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? A. Basal cell carcinomas B. Melanomas C. Actinic keratoses D. Squamous cell carcinomas

B

A nurse is caring for a client who has a positive tuberculin skin test and a new prescription for isoniazid. For which of the following laboratory values should the nurse monitor? A. Thyroid Stimulating Hormone level (TSH) B. Aspartate aminotransferase (AST) C. Potassium D. Sodium

B

A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial-thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN

B

A nurse is caring for a client who has been applying silver sulfadiazine cream to a deep partial-thickness arm burn for the past 2 weeks. The nurse should monitor the client for which of the following adverse effects? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN

B

A nurse is caring for a client who has developed MRSA in a surgical incision. Which of the following medications should the nurse expect the provider to prescribe? A. Ceftriaxone B. Vancomycin C. Ketoconazole D. Ciprofloxacin

B

A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as a part of an effective conference? A. The planning process for the conference is centered on the nursing staff. B. Other health care professionals are in attendance at the conference. C. Controversial opinions contributed to the plan of care are not tolerated during the conference. D. The conference focuses on a discussion of the client's heath care issues with minimal focus of resolving them.

B

A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for isoniazid. Which of the following instructions should the nurse include? A. "You'll need to take this medication for the rest of your life to prevent recurrence." B. "Your provider will monitor your liver function while you are taking this medication." C. "Limit your alcohol intake to 2 drinks per day." D. "You should take this medication with a meal to increase absorption."

B

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? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum

B

While caring for a client, a nurse notices that the client's call light cord is frayed. Which of the following actions should the nurse take? A. Tell the client not to use the call light until it is fixed B. Replace the call light and send the frayed light to the repair department C. Tape the frayed area of the cord until maintenance can be notified so the client can continue using it D. Give the client a bell and tell him to use the call light for emergencies

B

nurse notes the client has a severe penicillin allergy. Which of the following class of antibiotics is also contraindicated for this client? A. Carbapenems B. Cephalosporins C. Aminoglycosides D. Fluoroquinolones

B

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. The nurse finds the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

BCDE

A nurse in a clinic is caring for a client who has returned for a follow-up visit after treatment of a laceration on her upper arm. Which of the following actions should the nurse perform when removing the sutures that the client received at her last visit? A. Assure the client that the procedure will not cause any discomfort B. Clip the suture twice on each side of the knot C. Clip the suture as close to the skin as possible D. Wear clean gloves throughout the procedure

C

A nurse in a dermatology clinic is using the ABCDE method while screening several of a client's skin lesions for skin cancer. Which of the following findings should the nurse report to the provider? A. Symmetric shape B. Border regularity C. Color variation within a lesion D. Diameter >4 mm

C

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? A. Re-apply sunscreen every 4 hr during sun exposure B. Wear a sun visor instead of a hat when outside in the sun C. Avoid exposure to the midday sun D. Use a tanning booth instead of sunbathing outdoors

C

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid and electrolyte imbalances should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

C

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant? A. Don a gown before entering the room and remove it before exiting B. Wear a mask while in the client's room C. Don gloves when entering the room and use hand sanitizer when exiting D. Take no special precautions unless engaging in direct contact with the client

C

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Apply a gown when in the client's room D. Dispose of all bed linens used by the client

C

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 nurse's priority? A. Monitor intake and output B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake

C

A nurse is collecting data from a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect to see? A. Confluent, honey-colored, crusted lesions B. Large tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. Fluid-filled vesicular rash in the genital region

C

A nurse is reinforcing teaching with a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication with food." B. "I need to take a B-complex vitamin while taking this medication." C. "I can expect this medication to turn my skin orange." D. "I can expect this medication to make my vision blurry."

C

A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take? A. Apply an abdominal binder B. Apply dry, sterile gauze over the incision C. Position the client supine with the knees in flexion D. Place gentle pressure with an abdominal pad over the evisceration

C

A nurse is reviewing the laboratory results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective

C

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? A. Cigarette smoking B. Low-fiber diet C. Excessive exposure to ultraviolet light D. Human papillomavirus

C

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. "Clean the lesions twice a day with hydrogen peroxide." B. "Apply a hot compress to the affected areas." C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." D. "Expect to receive penicillin prior to delivery."

C

A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C

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? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound

C

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use a staple remover and remove each suture individually." B. "Bandage scissors are used to cut the sutures." C. "Tweezers are necessary only for removal of retention sutures." D. "I will clip each suture close to the skin and pull it through from the other side."

D

A nurse enters a client's room and notices smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Attempt to extinguish the fire C. Activate the facility's fire alarm system D. Transport the client to an area away from the smoke

D

A nurse is caring for a client who is recovering at home after receiving inpatient treatment for burn injuries. To increase the protein density of the client's meals, which of the following recommendations should the nurse share with the client's caregiver? A. Use sour cream instead of plain yogurt B. Add honey to cooked cereals C. Use salad dressing in place of mayonnaise D. Add chopped, hard-cooked eggs to soups and casseroles

D

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a grainy appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin

D

A nurse is collecting data from a client who has tuberculosis and a prescription for ethambutol. The nurse should inform the client that he is likely to develop which of the following alterations as an adverse effect of this medication? A. Mottling of the extremities B. Orange-red urine and bodily secretions C. Yellowing of the sclera D. Loss of red/green color discrimination

D

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? A. Edema in the affected extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1° C (102.4°F)

D

A nurse is contributing to the plan of care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures? A. Curettage B. External radiation therapy C. Regional chemotherapy D. Surgical excision

D

A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids should the nurse identify as contraindicated for this client? A. Whole blood B. Lactated Ringer's C. Dextran 40 in 0.9% sodium chloride D. 0.45% sodium chloride

D

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? A. Wear nylon socks with shoes every day B. Trim toenails by rounding the edges of the nail C. Apply lotion between the toes after bathing D. Test water temperature with the wrist

D

A nurse is reinforcing teaching about home care with the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. Dry the affected area with a hair dryer on the low setting twice per day B. Use cloth diapers washed in a low-residue detergent C. Wash the genital area vigorously with each diaper change D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes

D

A nurse is caring for a child who has electrical burns on her lower arms and hands. Which of the following findings indicates the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain

A

A nurse is caring for a client who has tuberculosis and is taking rifampin. Which of the following client statements should indicate to the nurse that the client is experiencing an adverse effect of the medication? A. "I have noticed my urine is orange in color." B. "I sleep more than I used to." C. "My tongue and mouth are sore." D. "My voice seems hoarse."

A

A nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states, "Something just popped when I coughed." Which of the following actions should the nurse take first? A. Cover the client's wound with a sterile, moist dressing B. Flex the client's knees C. Reassure the client D. Instruct the client to avoid coughing

A

A nurse is collecting data from a client who has a Clostridium difficile infection and is receiving vancomycin via intermittent IV bolus over 60 minutes. The nurse should document the absence of which of the following conditions as a positive response to this slowed administration rate? A. Red man syndrome B. Thrombophlebitis C. Renal failure D. Ototoxicity

A

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation." D. "You should schedule a cesarean birth after your water breaks."

A

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? A. "I will be on a special shower table." B. "The water temperature will be very cool to ease my pain." C. "The nurse will use a firm-bristled brush to remove loose skin." D. "The nurse will use scissors to open small blisters."

A

A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? A. Zoster vaccine B. Acyclovir C. Amoxicillin D. Infliximab

B

A nurse in an 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? A. Estimation of burn injury B. Respiratory rate C. Presence of bowel sounds D. Level of pain

B

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

A

A nurse is assigned to care for several clients who are postoperative. The nurse should identify that the client taking which of the following medications is at risk for delayed wound healing? A. Nifedipine to treat hypertension B. Prednisone to treat persistent arthritis exacerbations C. Albuterol to treat asthma D. Chlorpromazine to treat schizophrenia

B

A nurse is collecting data from a client who is 3 days postoperative following abdominal surgery. The client's incision is slightly edematous, appears pink with crusting on the edges, and is draining serosanguinous fluid. Which of the following statements describes this incision? A. The incision is showing early signs of infection. B. The incision is showing early signs of dehiscence. C. The incision is showing signs of healing without complications. D. The incision is showing signs of developing a fistula.

C

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? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite

C

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? A. Vitamin B1 B. Calcium C. Vitamin C D. Potassium

C

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? A. Solid color B. Symmetrical shape C. Less than 6 mm in diameter D. Irregular border

D

A nurse is reinforcing teaching with a client who has a urinary tract infection and new prescriptions for phenazopyridine and ciprofloxacin. Which of the following statements by the client indicates the need for further teaching? A. "If phenazopyridine upsets my stomach, I can take it with meals." B. "Phenazopyridine will relieve my discomfort, but ciprofloxacin will get rid of the infection." C. "I need to drink 2 liters of fluid per day while I am taking ciprofloxacin." D. "I should notify my provider immediately if my urine turns orange."

D

A nurse is reinforcing teaching with a client who has genital herpes about self-management. Which of the following instructions should the nurse include in the teaching? A. Use an alcohol-based soap to clean lesions B. Wear a condom during sexual activity when lesions are present C. Take a sitz bath once per day D. Pour running water over the lesions when urinating

D

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? A. "Move between the bed and the wheelchair once every 2 hours." B. "Make sure that your caregiver massages your skin daily." C. "Use a rubber ring when sitting in the wheelchair." D. "Shift your weight in the wheelchair every 15 minutes."

D

A nurse is teaching a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.

D

A nurse is working with an assistive personnel (AP) assigned to bathe a client who has herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following responses should the nurse make? A. "Adults receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox." B. "Herpes zoster is not contagious to individuals who received an MMR vaccine as an infant." C. "A client who has herpes zoster is not contagious if blisters are present on the skin." D. "Herpes zoster is contagious to people who have never had chickenpox."

D

A nurse is reinforcing teaching about skin changes in older adult clients with a newly licensed nurse. Which of the following findings should the nurse identify as a benign, age-related skin change commonly seen in older adult clients? A. Liver spots B. Nevi C. Atopic dermatitis D. Psoriasis

A

A nurse is caring for a client who has developed a mild Clostridium difficile infection following antibiotic therapy. After discontinuing the current antibiotic, the nurse should expect the provider to prescribe which of the following medications? A. Vancomycin B. Metronidazole C. Clindamycin D. Ciprofloxacin

B

A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? A. Cadaver skin B. Pig skin C. Amniotic membranes D. Beef collagen

B

A nurse is collecting data from a client who has systemic scleroderma. Which of the following findings should the nurse expect? A. Excessive salivation B. Skin tightening C. Periorbital edema D. Alopecia

B

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 client's sacral area. The nurse should document that the client has a pressure ulcer at which of the following stages? A. IV B. I C. III D. II

D

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A

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 indicates that she has adapted to her changed body image? A. "May I go with my family to the visitor's lounge?" B. "I'll see my friends someday when I feel better." C. "My dad is coming to visit. Can you fix my hair for me?" D. "I told my cousins I'm in protective isolation."

A

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? A. Bacterial growth B. Scarring C. Skin graft size D. Pain

A

A nurse is caring for a client who has tuberculosis and is taking rifampin. The nurse should monitor the client for which of the following findings as an adverse effect of rifampin? A. Red-tinged urine B. Tinnitus C. Blurred vision D. Dry mouth

A

A nurse is reinforcing discharge teaching with a client who is postoperative 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? A. Ulceration B. Blanching of surrounding skin C. Dimpling D. Fading of color

A

A nurse in a clinic is reinforcing education with a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight." B. "You will need extensive dermatological treatment for this condition after you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."

A

A nurse in a community health clinic is collecting data from a new client who has prescriptions for isoniazid and rifampin. Which of the following disorders should the nurse expect the client to have? A. Tuberculosis B. Hypertension C. Diabetes D. Cirrhosis

A

A nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles

A

A nurse in an urgent care clinic is caring for a client who has a snakebite on her arm. Which of the following actions should the nurse take? A. Immobilize the limb at the level of the heart B. Apply a tourniquet to the affected limb C. Use a sterile scapula to incise the wound D. Apply ice to the skin over the snakebite wound

A

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 the acute phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises. B. Use clean technique to provide wound care. C. Place the client on a low-protein diet. D. Maintain the client on bed rest.

A

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme

A

A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin? A. Red-orange discoloration of urine B. Increased ecchymosis C. Yellow appearance of the sclerae D. Lack of energy

A

A nurse is reinforcing teaching with a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."

B

A nurse is caring for a client who has a stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C

A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the highest protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices

D

A nurse is caring for a client who has regular occupational exposure to sunlight and presents to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A. A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder B. Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose C. A raised, circumscribed lesion on the face that contains yellow-white purulent material D. An irregularly shaped brown lesion with light blue areas on the neck

D

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan? A. "Your partner needs to be cultured and treated with metronidazole only if his cultures are positive." B. "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative." C. "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." D. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative."

D

A nurse is collecting data from a client who has an arm lesion. Which of the following characteristics is a clinical manifestation of malignant melanoma? A. Rough, dry, and scaly B. Firm nodule with crust C. Pearly papule with an ulcerated center D. Irregularly shaped with blue tones

D