Integumentary Disorders Practice Questions

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is a priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.

Answer: 1 1. After the airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes. 2. This is important, but it is not a priority over fluid volume balance, and this is not a collaborative intervention because the nurse can do this independently. 3. Output must be monitored, but this is an independent intervention. 4. An escharotomy, an incision that releases scar tissue that prevents the body from being able to expand, enables chest excursion in circumferential chest burns. The client has not had time to develop eschar. TEST-TAKING HINT: A collaborative intervention is an intervention that requires an HCP's order or working with another discipline. Therefore, options "2" and "3" should be eliminated immediately.

The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure injuries? 1. Constant perineal moisture. 2. Ability of the clients to reposition themselves. 3. Decreased elasticity of the skin. 4. Impaired cardiovascular perfusion of the periphery.

Answer: 1 1. All the skin should be kept free of moisture. It is within the realm of nursing to provide this service. Clients with constant moisture on the skin are at high risk for impaired skin integrity. 2. The clients able to reposition themselves would have decreased chances of developing pressure injuries. This would not be a risk factor. 3. Decreased elasticity occurs with aging, and it is not modifiable. 4. Impaired cardiovascular perfusion of the skin in the periphery is not modifiable. TEST-TAKING HINT: The test taker must read the stem carefully. Which situation can the nurse modify with nursing care? The nurse cannot modify the changes that occur with aging or the sequelae that occur with disease processes.

The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client diagnosed with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.

Answer: 1 1. Although this is a potential problem, it is a priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response. 2. This psychosocial client problem is important, but in the ICU, the first priority is preventing infection so wound healing can occur. 3. Burn wound edema, pain, and potential joint contractures can cause mobility deficits, but the first priority is preventing infection so wound healing can occur. 4. Teaching is always important, but in the ICU, the priority is the physiological integrity of the client. TEST-TAKING HINT: The adjectives "intensive care" mean the client is critically ill; therefore, a physiological problem is a priority and options "2" and "4" can be eliminated. Although actual problems are usually higher priority than potential problems, in the case of a burn, the risk for infection has to be the priority.

The client comes to the emergency department reporting pain in the left lower leg following a puncture wound from a nail in a plywood board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8°F. Which condition would the nurse suspect the client is experiencing? 1. Cellulitis. 2. Lyme disease. 3. Impetigo. 4. Deep vein thrombosis.

Answer: 1 1. Cellulitis is a bacterial infection of the subcutaneous tissue usually associated with a break in the skin, and the nurse would suspect this with these clinical manifestations. 2. Lyme disease is caused by the bite of a tick, resulting in a bull's-eye-appearing lesion. 3. Impetigo is characterized by large, fluid-filled blisters and is very contagious. 4. Deep vein thrombosis clinical manifestations are a reddened, warm calf, and pain on ambulation, but this condition is not caused by a nail puncture; it is caused by immobility. TEST-TAKING HINT: If the test taker does not know the answer, the test taker should look at the stem and identify that redness and fever are clinical manifestations of inflammation; -itis means "inflammation" and option "1" would be an appropriate selection.

The nurse is assessing a young mother in the clinic reporting sores on her skin. Which assessment data would support that the client has chickenpox? 1. Crops of lesions that have pus and reddened base. 2. Oval scaling lesions that occur on the legs and arms. 3. Severe itching of the scalp with tiny eggs visible. 4. Ringed red lesions on the face, neck, trunk, and extremities.

Answer: 1 1. Chickenpox starts out with a macular rash. The lesions appear in crops first on the trunk and scalp, and then lesions move to the extremities. Then, they change to teardrop vesicles with an erythematous base and become pustular. Finally, they dry. 2. Oval scaling indicates fungal infections. 3. Severe itching of the scalp with tiny eggs visible supports the diagnosis of lice. 4. Ringed red lesions support the diagnosis of ringworm. TEST-TAKING HINT: This is primarily a knowledge-based question. The test taker either knows the clinical manifestations of different skin disorders or does not. One way to help identify the answer is to try to determine what condition each option describes. For example, "tiny eggs" should make the test taker think of a parasite (lice).

The nurse administered morphine sulfate IVP 45 minutes ago to a client diagnosed with herpes zoster. On reassessment, the client reports the pain decreased to a "5" on a 1-to-10 scale. Which intervention should the nurse implement? 1. Turn on soft music and shut the blinds. 2. Apply warm, moist heat to the lesions. 3. Notify the HCP for more pain medication. 4. Encourage the client to ambulate with assistance.

Answer: 1 1. Diversionary techniques, including music and television, are often used in conjunction with medication to manage pain. Shutting the blinds will help provide a calm, quiet atmosphere. 2. Warm, moist heat will exacerbate the pain from the lesions; cool compresses would help. 3. The client was medicated 45 minutes ago and would not be able to have more morphine sulfate, a narcotic analgesic; therefore, there is no reason to notify the HCP. 4. Ambulating will not help decrease the client's pain and could aggravate it. In addition, the client has been given morphine, which causes drowsiness and could lead to a safety issue. TEST-TAKING HINT: The test taker could rule out option "4" with no knowledge of the disease process because the nurse does not ambulate clients on morphine. The nurse often uses diversionary interventions when addressing pain issues.

The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement? 1. Teach the parents to ensure the child takes all the prescribed antibiotics. 2. Give the parents a written excuse so the child can go back to school. 3. Encourage the parents to bathe the child in an oatmeal bath for the itching. 4. Apply topical lidocaine before debriding the crusts from the lesions.

Answer: 1 1. Impetigo is a group A beta-hemolytic streptococci or staphylococci infection treated with antibiotics; the parents should make sure that all medication is taken as directed. 2. The child has a contagious infection and is not allowed to return to school until the infection has resolved itself. 3. Oatmeal baths are useful to treat the pruritus of poison ivy or oak but are not used for bacterial infections. 4. The nurse would not débride the lesions. Sometimes soap and water are used to soften the crusts from the lesions. TEST-TAKING HINT: Standard instructions to all clients regarding antibiotics are to finish them all to treat the infection and prevent regrowth of resistant bacteria from partially treated infection.

The client is admitted to the outpatient surgery center for the removal of a malignant melanoma. Which assessment data indicate the lesion is malignant melanoma? 1. The lesion is asymmetrical and has irregular borders. 2. The lesion has a waxy appearance with pearl-like borders. 3. The lesion has a thickened and scaly appearance. 4. The lesion appeared as a thickened area after an injury.

Answer: 1 1. Malignant melanomas are the most deadly of skin cancers. Asymmetry, irregular borders, variegated color, and rapid growth are characteristics of them. 2. A waxy appearance and pearl-like borders are characteristic of basal cell carcinoma. 3. A thickened and scaly appearance describes squamous cell carcinoma. 4. A thickened area after an injury describes a benign condition called a keloid. TEST-TAKING HINT: This is a knowledge-based question, but it does indicate the differences in the types of skin lesions. The test taker should concentrate on the differences when studying for an examination.

The client has tinea pedis. Which intervention should the nurse teach to the client? 1. Soak feet in a vinegar-and-water solution. 2. Wear shoes without any type of socks. 3. Alternate shoes on a monthly basis. 4. Cut toenails straight across.

Answer: 1 1. Soaking the feet will help remove the crust, scales, and debris to reduce the inflammation in a client diagnosed with athlete's foot. Vinegar is mildly acidic, which helps remove crusts, although the efficacy of home remedies has not been completely evaluated. 2. White cotton socks should be recommended to help prevent athlete's foot. Colored socks have dyes that irritate the skin, and cotton socks absorb moisture. 3. Several pairs of shoes should be alternated so that shoes can be completely dry before wearing them again. 4. Cutting toenails straight across is correct, but it will not prevent or treat athlete's foot. TEST-TAKING HINT: There are basic interventions that are taught about foot care in general, and trimming toenails is one of them. This could apply to many foot conditions. Wearing socks is always advisable because feet perspire. Not very many interventions are done on a monthly basis—usually daily or weekly—so option "3" can be eliminated.

The female teacher comes to the school nurse's office and shows the nurse a rash on her hands. The nurse tells the teacher she has probably contracted impetigo from one of the students. Which intervention should the nurse implement? 1. Instruct the teacher to go to her HCP today. 2. Tell the teacher to wash her hands with soap and water. 3. Encourage the teacher to rub vitamin E oil on the lesions. 4. Explain that the rash will go away in a few days.

Answer: 1 1. Systemic antibiotics are the treatment of choice for impetigo. Therefore, the teacher must go to the HCP to get the prescription today because impetigo is highly contagious. 2. Washing hands is always a good practice, but the teacher needs medication for this bacterial infection. 3. Vitamin E oil does help prevent scarring, but it will not treat this bacterial infection. 4. Impetigo is not a rash; it is raised, crusty lesions. TEST-TAKING HINT: The test taker must know that impetigo is a bacterial infection requiring medical treatment. Vitamins do not treat skin infections. Washing with an antiseptic solution may help, but antibiotics are the treatment of choice.

The client diagnosed with paraplegia is being admitted to a medical unit from home with a stage IV pressure injury over the right ischium. Which assessment tool should be completed on admission to the hospital? 1. Complete the Braden Scale. 2. Monitor the Glasgow Coma Scale. 3. Assess for Babinski's sign. 4. Initiate a Brudzinski flow sheet.

Answer: 1 1. The Braden and Norton scales are tools that identify clients at risk for skin problems. This client should be ranked on this scale, and appropriate measures should be initiated for controlling further damage to the skin. 2. The Glasgow Coma Scale is a neurological coma scale used to determine the depth of neurological damage. 3. Assessment for Babinski's sign would not be attempted with a client paralyzed from the waist down. The nerve pathways are not working. 4. Brudzinski's sign is used to assess for meningitis. TEST-TAKING HINT: The test taker must memorize the specific diagnostic tools used to assess clients.

The RN in the long-term care facility must delegate a nursing task to a UAP. Which nursing task would be most appropriate to delegate? 1. Comb the nits out of the client's hair. 2. Massage the reddened area on the hip. 3. Scrape the burrows to remove the scabies mite. 4. Apply antifungal lotion to the groin area.

Answer: 1 1. The assistant could use a fine-toothed comb dipped in vinegar to remove any nits in the hair of the client with lice. 2. Reddened areas should not be massaged; that will lead to further damage. 3. Scraping the burrows is a diagnostic test and cannot be delegated to an assistant. 4. Assistants cannot administer medication. TEST-TAKING HINT: The test taker must apply universal delegation rules. Nurses cannot delegate medication administration or diagnostic tests. Some states allow medication aides to administer routine medications to clients in long-term care facilities, but the stem does not identify this employee as a medication aide. Do not read into the question.

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.

Answer: 1 1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery. 2. The client should be provided a high-calorie, high-protein diet along with vitamins. 3. The client should be weighed daily, and the goal is that the client loses no more than 5% of the preburn weight. 4. The nurse would make a referral to a dietitian, not a social worker. TEST-TAKING HINT: The nurse needs to be knowledgeable regarding different types of diets; this requires memorization.

The client has had a squamous cell carcinoma removed from the lip. Which discharge instructions should the nurse provide? 1. Notify the HCP if a nonhealing lesion develops around the mouth. 2. Squamous cell carcinoma tumors do not metastasize. 3. Limit foods to liquid or soft consistency for 1 month. 4. Apply heat to the area for 20 minutes every 4 hours.

Answer: 1 1. The client should be aware of clinical manifestations that indicate the development of another skin cancer. Squamous cell carcinoma can develop in areas of the skin and mucous membranes. 2. Of deaths from squamous cell carcinomas, 75% occur because of metastasis. Even basal cell carcinoma can metastasize but is usually so slow-growing that surgical excision removes cancer if the client does not delay treatment. 3. The surgery was on the lip, not in the mouth. Food can be of a regular consistency. 4. Applying heat to the area would increase circulation and edema, increasing the client's discomfort. TEST-TAKING HINT: Anatomical positioning ("lip") could eliminate option "3." An HCP should be notified of any nonhealing wound.

The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first? 1. The crying client scheduled for a skin biopsy. 2. The client 3 hours postoperation now sleeping. 3. The client needing to void before discharge. 4. The client receiving discharge instructions and ready to go home.

Answer: 1 1. This client has an unexpected situation occurring and should be assessed before any stable client. 2. This client's surgery was 3 hours ago, and the client should be stable and allowed to rest. 3. This client can be seen after assessing the client in option "1." 4. This client could be escorted to the door by a UAP; another nurse has already prepared the client for discharge. TEST-TAKING HINT: Physiological problems usually have priority over psychological ones, but none of the other clients has a life-threatening or life-altering situation. The only unexpected situation is the crying client.

Which individual would most likely experience the skin disorder pseudofolliculitis barbae (shaving bumps)? 1. A male African American soldier. 2. A female white hairdresser. 3. A male Asian food server. 4. A female Hispanic schoolteacher.

Answer: 1 1. This disease is a bacterial inflammatory reaction that occurs predominantly on the faces and necks of curly-haired men as a result of shaving. The sharp in-growing hairs have a curved root that grows at a more acute angle and pierces the skin. The treatments are to apply creams and not to shave. 2. This person will not get this disease. 3. This person will not get this disease. 4. This person will not get this disease. TEST-TAKING HINT: If the answer to this question is not known, the test taker could examine the root words and endings: Follicle refers to "hair" and -itis is an inflammation. The test taker should think about what type of hair each individual has and realize that African Americans typically have curly hair.

The public health nurse is providing a class on skin disorders in the African American community. Which information should the nurse include in the presentation? 1. People with dark skin suffer the same skin conditions as people with light skin. 2. African American men are more likely to have skin cancer than women. 3. Dark-skinned individuals are less likely to form keloids after any type of surgery. 4. Buccal mucosa of dark-skinned individuals is usually a bluish-tinged color.

Answer: 1 1. This is the correct information. 2. Dark-skinned people are less likely to have skin cancer. 3. Dark-skinned people are more likely to have keloids (hypertrophied scar tissue) after surgery. 4. Bluish-tinged buccal mucosa in anyone indicates decreased oxygenation. TEST-TAKING HINT: The nurse should know that any blue color on the body is abnormal, thus ruling out option "4." The test taker should notice that options "2" and "3" have "more likely" and "less likely," which may encourage the test taker to rule out both answers and select option "1."

The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions? 1. Use a pillow to keep the heels off the bed when supine. 2. Order a low air-loss therapy bed immediately. 3. Prepare to insert a nasogastric feeding tube. 4. Order an occupational therapy consult for strength training.

Answer: 1 1. Using a pillow to suspend the heels off the bed when a client is supine prevents the development of pressure injuries on the heels. 2. Low air-loss therapy beds are expensive and normally are provided only for clients diagnosed with stage III or stage IV impaired skin integrity. An egg-crate mattress may be applied to the bed for pressure relief, but many hospitals now have changed all of their regular mattresses for ones that provide the same pressure reduction surface as an egg-crate mattress. 3. There is no indication that the client requires tube feeding. 4. Physical therapists, not occupational therapists, work with clients on strength training. Occupational therapists address activities of daily living deficits. TEST-TAKING HINT: The test taker should not read into the question. The stem did not mention any swallowing problem, only a mobility problem. The correct answer must relate to the information provided in the stem.

The nurse in a dermatology clinic is taking the history of a client. Which questions should the dermatology nurse ask the client? Select all that apply. 1. When did you first notice the skin problem? 2. What cosmetics or skin products do you use? 3. Have you experienced any loss of sensation? 4. What is your current and previous occupation? 5. Do you experience any itching, burning, or tingling?

Answer: 1, 2, 3, 4, 5 1. Dermatology is the study of the skin. Therefore, asking about skin problems is appropriate. 2. The nurse must differentiate between dermatitis, which could result from a cosmetic or other skin product, and skin infection. 3. The skin is responsible for sensation, so any loss would be significant. 4. Many occupations, including those involved in working with chemicals, predispose a client to abnormal skin conditions. 5. These are hallmark clinical manifestations of skin abnormality. TEST-TAKING HINT: In "Select all that apply" questions, each option stands or falls on its own. The test taker should not try to second-guess the item writer by thinking that there is no way that all five options will be correct.

Which nursing interventions should be included for the client diagnosed with full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change the central lines once a week. 5. Administer antibiotics as prescribed.

Answer: 1, 2, 3, 5 1. Hand washing is the number-one intervention used to prevent infection, which is a priority for the client diagnosed with a burn. 2. Aseptic techniques minimize the risk of cross-contamination and the spread of bacteria. 3. Aseptic techniques minimize the risk of cross-contamination and the spread of bacteria. 4. Central lines are not changed unless they are no longer needed or the client has developed an infection related to the line. The central line catheter hubs, connectors, injection ports, and dressings are changed every 2 days for gauze dressings or every 7 days for semipermeable dressings. Dressings are changed if wet or visibly soiled (The Joint Commission, 2019). 5. Antibiotics reduce bacteria. TEST-TAKING HINT: Alternative-type questions require the test taker to choose all options that apply. Infection is a priority for clients diagnosed with burns.

The client is diagnosed with disseminated herpes zoster secondary to AIDS. Which interventions should the nurse implement? Select all that apply. 1. Place the client in contact isolation. 2. Administer a corticosteroid IVP. 3. Assess the client's pain on a 1-to-10 scale. 4. Request that the client not have any visitors. 5. Ensure nurses with prior chickenpox infection care for this client.

Answer: 1, 2, 3, 5 1. The zoster lesions are contagious, so the client should be in contact isolation. 2. Corticosteroids decrease the inflammation, which helps with the healing process. 3. Assessment is always an appropriate intervention. 4. The client can have visitors as long as they do not have an infection that the client could get and the visitors comply with isolation protocol. Only visitors with prior chickenpox infection should be allowed to visit. 5. Herpes zoster is the same virus that causes chickenpox. It was thought for years that there were two separate viruses. Research has proven that the varicella virus and zoster are the same; therefore, only nurses with prior chickenpox infection should care for this client. TEST-TAKING HINT: This is an alternate-type question where the test taker must select all the interventions that are pertinent. If the test taker is aware that corticosteroid medications decrease inflammation, then option "2" should be selected as a correct answer. Assessment (option "3") is always an appropriate selection if the assessment data apply to the situation.

The school nurse is assessing a teacher with pediculosis. Which statement by the teacher makes the nurse suspect that the teacher complied with the instructions discussed in the classroom? Select all that apply. 1. "I used the comb to remove all the nits." 2. "I washed my hair with pyrethrin shampoo." 3. "I removed all the sheets from my bed." 4. "I had to fix my daughter's hair with my brush." 5. "I sealed my favorite fur-lined hat in a plastic bag."

Answer: 1, 2, 3, 5 1. This statement indicates the teacher understands the teaching about the spread of lice (pediculosis). 2. Pyrethrin (Rid) is a recommended over-the-counter medication to use when lice are found in the hair. Lindane (Kwell) shampoo is no longer recommend by the American Academy of Pediatrics as a pediculicide. 3. All linens and pertinent clothing should be washed in hot water to help destroy the eggs. 4. Sharing brushes is one of the main ways that lice are spread. Therefore, this statement indicates the teacher did not comply with the instructions. 5. Any items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for 2 weeks to destroy the lice. TEST-TAKING HINT: This is an alternative format question. Therefore, more than one of the options will be correct actions for the problem. The test taker should always read all the options thoroughly.

The RN and a UAP are caring for clients in a dermatology clinic. Which task should be delegated to the UAP? Select all that apply. 1. Stock the rooms with the equipment needed. 2. Weigh the clients and position the clients for the examination. 3. Discuss the problems the client has experienced since the previous visit. 4. Identify any teaching needs the clients may have at this visit. 5. Take the biopsy specimens to the laboratory.

Answer: 1, 2, 5 1. The UAP can restock rooms. 2. These activities can be performed by a trained UAP. 3. This is part of assessing the client and cannot be delegated. 4. This is part of assessing the client and cannot be delegated. 4. This is an appropriate delegation. TEST-TAKING HINT: This is an alternative format question. The test taker must be careful to read the question and determine which activities the UAP can perform.

The HCP prescribed malathion lotion to be applied to the head. Which instructions should the nurse teach the client concerning this medication? Select all that apply. 1. Leave the lotion on for 8 hours after applying it to the hair. 2. Make sure that the hair is dry before applying the lotion. 3. Repeat the hair lotion application daily for at least 1 week. 4. Put the lotion in the bathwater and soak for at least 20 minutes. 5. Avoid hair dryers, cigarettes, or open flames during treatment.

Answer: 1, 2, 5 1. The malathion (Ovide) lotion should be left on for at least 8 to 12 hours to be effective. 2. The manufacturer recommends that malathion (Ovide) lotion be applied to dry hair until the scalp and hair are wet and thoroughly coated. 3. One application may cure the infestation of lice or scabies, but another application may be needed in 1 week; daily administration is contraindicated. 4. This medication must be applied to dry hair, not introduced into bathwater. 5. Malathion (Ovide) lotion is flammable. The lotion and wet hair should not be exposed to heat sources or open flames. TEST-TAKING HINT: The test taker should always be aware of time frames, notice "8 hours," "20 minutes," and "daily." These are all terms that may help the test taker to choose the correct answer.

The nurse has written the concept of impaired skin integrity for a client diagnosed with diabetes mellitus type 2 and an acute, infected wound on the left heel. Which interventions should the nurse implement? Select all that apply. 1. Administer antibiotics via IVPB method. 2. Perform wound dressing changes using unsterile gloves. 3. Monitor blood glucose levels. 4. Assess the client's culture daily. 5. Encourage the client to comply with the recommended diet.

Answer: 1, 3, 5 1. The wound is infected so antibiotics should be administered. In the hospital, most antibiotics are administered via IVPB. 2. Dressing changes should be performed with sterile, not unsterile gloves due to the "acute" nature of the injury. Dressing changes for some chronic wounds may be done with unsterile gloves, but even a chronic wound in an immunosuppressed client should be performed as a sterile procedure (Treas, Wilkinson, Barnett, & Smith, 2018). 3. High blood glucose levels impair wound healing and encourage bacterial growth. 4. The client will not have daily cultures, and after an antibiotic is initiated, the culture will be skewed. 5. Controlling the glucose levels will assist the client in promoting wound healing and disease stabilization. TEST-TAKING HINT: When answering a "Select all that apply" question, the test taker must look at each option independently of the other options. Each option becomes a true or false question.

The female client calls the clinic and tells the nurse that she has a really big "boil" in the perineal area that is causing a lot of pain. Which intervention should the nurse implement? 1. Schedule an emergency appointment for the client. 2. Instruct the client to apply warm, moist compresses to the area. 3. Determine if someone can squeeze the boil. 4. Explain that this will resolve on its own.

Answer: 2 1. A furuncle (boil) is not a life-threatening emergency, and an appointment is not needed for this client. 2. Warm, moist compresses increase vascularization and hasten the resolution of the furuncle. 3. With staphylococcal infections, such as a boil, it is important not to rupture the protective wall of induration that localizes the infection. 4. The client called the clinic to get help, and this response does not help the client. A nurse can recommend heat, ice, elevation, or some type of independent treatment. TEST-TAKING HINT: The test taker can always rule out options that don't address the client's needs, such as option "4." Option "3" can also be ruled out: There are very few "never," answers, but one is never squeezing or popping a boil or pimple.

The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before the pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.

Answer: 2 1. Addressing pain will not address impaired skin integrity. 2. Daily cleaning reduces bacterial colonization. 3. This intervention would be appropriate for a "risk for infection" nursing diagnosis. 4. Plants and flowers in water should be avoided because stagnant water is a source of bacterial growth. TEST-TAKING HINT: The intervention addresses the etiology of the nursing diagnosis "open burn wounds," and the goal addresses the response "impaired skin integrity."

The school nurse is discussing impetigo with the teachers in an elementary school. One of the teachers asks the nurse, "How can I prevent getting impetigo?" Which statement would be the most appropriate response? 1. "Wash your hands after using the bathroom." 2. "Do not touch any affected areas without gloves." 3. "Apply a topical antibiotic to your hands." 4. "Keep the child with impetigo isolated in the room."

Answer: 2 1. Cleanliness and good hygiene prevent the spread of impetigo, but washing hands after going to the bathroom will not prevent the spread. 2. Lesions are extremely contagious and should not be touched, except when wearing gloves. 3. The topical antibiotic ointment is applied after impetigo has developed. It will not help prevent impetigo. Usually, the client diagnosed with impetigo is given systemic antibiotics. 4. The child is kept at home until after taking antibiotics for at least 48 hours; the child is not isolated in the room. TEST-TAKING HINT: The test taker needs to think about what the options are saying. Option "4" can be eliminated because a child cannot be isolated in a room with many other children in the room. Washing hands after using the bathroom (option "1") is a general hygiene tip encouraged for all individuals and is not specific to impetigo. The test taker should look at the word "prevent" in the stem; antibiotic ointment is only prescribed for bacterial infections, so option "3" should be ruled out as an answer.

There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection? 1. Use only hand-washing foam when caring for clients diagnosed with scabies. 2. Wear gloves when providing hands-on care for a client diagnosed with scabies. 3. Wash all linen and clothes in cold water and dry them outside in the sun. 4. Instruct clients to use plastic eating utensils for meals.

Answer: 2 1. Foam or soap and water can be used to clean the hands. 2. Because of the close living quarters, clients in long-term care facilities are at high risk of developing scabies. Clients may have poor hygiene as a result of limited physical ability, and the nursing staff may transmit the parasite. Therefore, the nursing staff should wear gloves to provide a barrier to the mites. 3. Linens and clothing should be washed in hot water and dried in a hot dryer cycle because the mites can survive up to 36 hours in linens. 4. Plastic eating utensils will not help prevent the spread of scabies. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, then the test taker should eliminate options "1" and "3" because of the words "only" and "all." There are very few absolutes in the health-care profession.

The client sustained a hot grease burn to the right hand and calls the emergency department for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.

Answer: 2 1. Ice should never be applied to a burn because this will worsen the tissue damage by causing vasoconstriction. 2. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage. 3. Blisters should be maintained intact to prevent infection. 4. The client should be told to go to the ED, not the doctor's office, for burn care. TEST-TAKING HINT: The test taker should select an answer that directly cares for the client's body. This eliminates options "3" (blisters have not formed yet) and "4." Therefore, the test taker has to decide between cool water and ice.

Which statement by the client diagnosed with chickenpox indicates that the client understands the teaching? 1. "I should put rubbing alcohol on the lesions twice a day." 2. "I should not scratch myself if at all possible. It might lead to scarring." 3. "I can go to work when my lesions have all disappeared." 4. "I need to take all my antibiotics no matter how I feel."

Answer: 2 1. Rubbing alcohol will cause tremendous pain and will not help the lesions disappear. 2. The lesions are very irritating, and the client will want to scratch them. Clients diagnosed with chickenpox should use calamine lotion, soak in oatmeal baths, and apply Benadryl topical cream or take oral Benadryl. 3. The lesions are considered contagious until they are dry and crusted over, usually in 5 to 7 days. The client does not have to wait until they have disappeared; this may take up to 2 or 3 weeks. 4. Chickenpox is a virus, and antibiotics are effective only with bacterial infections; antibiotics are not prescribed. TEST-TAKING HINT: The test taker may realize that options with absolutes such as "all" should not be selected as the right answer, but the test taker should notice that the "all" in option "2" is not used in the same manner as to mean "always."

1. The client comes into the emergency department in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial-thickness. 3. Full-thickness. 4. First degree.

Answer: 2 1. Sunburn is an example of this depth of burn; a superficial partial-thickness burn affects the epidermis and the skin is reddened and blanches with pressure. 2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema. 3. Full-thickness burns are caused by flame, electric current, or chemical burns and include the epidermis, entire dermis, and sometimes subcutaneous tissue and may also involve connective tissue, muscle, and bone. 4. A first-degree burn is another name for a superficial partial-thickness burn. TEST-TAKING HINT: The adjectives in the stem are the most important words that assist the test taker when selecting a correct answer.

The nurse observes the UAP squeezing the "blackheads" on an elderly client. Which action should the RN implement first? 1. Notify the unit manager of witnessing this activity. 2. Instruct the assistant to stop this behavior. 3. Demonstrate the correct way to care for the skin. 4. Complete an incident report regarding the action.

Answer: 2 1. The RN is responsible for providing correct information to the UAPs. This intervention would be appropriate if confronting the person has not altered the behavior. 2. This action could result in the client developing a skin infection and should be stopped immediately; therefore, stopping the behavior is the first intervention. 3. The RN must be a role model for the UAP and demonstrate the correct way to care for the client's skin, but it is not the first intervention. 4. An incident report may need to be completed to document the situation, but it is not the first intervention. TEST-TAKING HINT: When the question asks the test taker to select the first intervention, all four options may be possible actions, but only one should be done first. In this situation, the behavior must be stopped before performing any other interventions.

The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first? 1. Refer the client to an HCP for a biopsy of the area. 2. Assess the lesion for size, color, and symmetry. 3. Discuss end-of-life decisions with the client. 4. Report the sexually transmitted illness to the health department.

Answer: 2 1. The client may need a biopsy, but the nurse should assess the area before deciding to refer the client. 2. This is the first step in deciding how to help the client. The nurse should assess the lesion to determine if it could be a Kaposi's sarcoma tumor or a healing contusion. 3. This is important for all clients, even those without a chronic illness, but the question asks what should be done first. This is not the priority at this time. 4. AIDS is a reportable disease, but reporting is not the priority intervention. TEST-TAKING HINT: Assessment is the first step in the nursing process.

The nurse is caring for a client diagnosed with squamous cell skin cancer and writes a psychosocial problem of "fear." Which nursing interventions should be included in the plan of care? 1. Explain to the client that the fears are unfounded. 2. Encourage the client to verbalize the feeling of being afraid. 3. Have the HCP discuss the client's fear with the client. 4. Inform the client regarding all planned procedures.

Answer: 2 1. The diagnosis of cancer is concerning for clients; this is belittling the client's concerns and gives false reassurance. 2. This is the most commonly written therapeutic communication goal. This addresses the client's concerns. 3. The nurse is capable of discussing the client's concerns. Many clients feel more comfortable discussing fears with the nurse than with the HCP. 4. This should be done but does not directly address the client's problem. TEST-TAKING HINT: The test taker must read the question carefully to decide what the question is asking. The answer must address the problem of fear.

The RN and a UAP on a medical floor are caring for older and immobile clients. Which action by the UAP warrants immediate intervention by the RN? 1. The UAP elevates the head of the bed for a client able to self-feed with minimal assistance. 2. The UAP asks to take a meal break before turning the clients at the 2-hour time limit. 3. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift. 4. The UAP mixes a beverage thickener into a glass of water for the client diagnosed with difficulty swallowing.

Answer: 2 1. The head of a client eating in bed should be elevated. This is a correct action on the part of the UAP. 2. It is important to turn bedfast clients every 1 to 2 hours and to encourage them, if they are able, to make minor readjustments to their position at least every 15 minutes. Allowing the client to lie in the same position for at least another 30 minutes before being turned should not be allowed. 3. It is a courtesy to the oncoming staff to leave the rooms equipped to care for the clients. 4. Beverage thickener (Thick-It) frequently is added to the liquids of a client diagnosed with difficulty swallowing. TEST-TAKING HINT: This is an "except" question. All but one option will be actions that are encouraged on the part of UAP. The test taker could jump to the conclusion that option "1" is correct if the test taker did not pay attention to the phrase "warrants immediate intervention."

The female client admitted for an unrelated diagnosis asks the nurse to check her back because "it itches all the time in that one spot." When the nurse assesses the client's back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first? 1. Notify the HCP to check the lesion on rounds. 2. Measure the lesion and note the color. 3. Apply lotion to the lesion. 4. Instruct the client to have the HCP check the lesion.

Answer: 2 1. The nurse should complete an assessment of the lesion before notifying the HCP to check it. 2. This is part of assessing the lesion and should be completed. The ABCDEs of skin cancer detection include the following: (1) Asymmetry—Is the lesion balanced on both sides with an even surface? (2) Borders—Are the borders rounded and smooth or notched and indistinct? (3) Color—Is the color a uniform light brown or is it variegated and darker or reddish-purple? (4) Diameter—A diameter exceeding 4 to 6 mm is considered suspicious. (5) Evolving—Has the lesion changed during the past few weeks or months?. 3. This may help as a comfort measure, but it is not the first and most important action. 4. Instructing the client to notify the HCP to assess the lesion also, should be done but does not have priority. TEST-TAKING HINT: Assessment is the first step in the nursing process. The test taker should have a systematic decision-making model when determining a priority action.

The client diagnosed with a debilitating illness has developed multiple pressure injuries and reports to the nurse during a dressing change that he is "tired of it all." Which is the nurse's best therapeutic response? 1. "These wounds can heal if we get enough protein into you." 2. "Are you tired of the treatments and needing to be cared for?" 3. "Why would you say that? We are doing our best." 4. "Have you made out an advance directive to let the HCP know your wishes?"

Answer: 2 1. The question asks for a therapeutic response. This response addresses a physiological problem and does not address the client's concerns. 2. This is restating and clarifying; both are therapeutic responses. 3. The client does not owe the nurse an explanation for the client's feelings. "Why" is not therapeutic. 4. This does not address the client's feelings. TEST-TAKING HINT: When the stem asks the test taker for a therapeutic response, the correct answer must address the client's feelings.

The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client? 1. Encourage the client to get the chickenpox immunization. 2. Do not engage in oral sex if you have a cold sore on the mouth. 3. Wear nonsterile gloves when cleaning the genital area. 4. Do not share any type of towel or washcloth with another person.

Answer: 2 1. The virus that causes chickenpox is the varicella-zoster virus (human herpesvirus 3), not the herpes simplex virus. 2. Herpes simplex 1 and 2 are caused by the same virus. Herpes simplex 1 refers to orolabial lesions and herpes simplex 2 refers to genital lesions, which can be transferred from one area to the other. 3. The question is asking which intervention the nurse should teach the client, and there is no reason for the client to have to wear nonsterile gloves for self-care. That is appropriate for the nursing personnel. 4. Herpes simplex is not transmitted via towels or washcloths. TEST-TAKING HINT: In some instances, the test taker simply must know about the disease process. Sexually transmitted diseases are common, and the nurse should know about how to prevent, discuss, and treat them.

The nurse is caring for a client diagnosed with stage IV pressure injury on the left trochanter and coccyx. Which collaborative problem has the highest priority? 1. Impaired cognition. 2. Altered nutrition. 3. Self-care deficit. 4. Altered coping.

Answer: 2 1. This can be an independent nursing problem or a collaborative one, but it does not relate to pressure injuries. 2. Altered nutrition is a collaborative problem involving the nurse, dietitian, and HCP. The client will need a diet high in protein and vitamins if there is a chance for the client to heal. 3. Self-care deficit is an independent nursing problem. 4. Altered coping is an independent nursing problem and does not relate to skin integrity. TEST-TAKING HINT: The stem gives two clues to the answer—"collaborative" and "pressure injuries." Collaborative means that some other members of the health-care team must be involved and pressure injuries are the client's problem. The correct answer must consider both of these variables.

The 55-year-old client contracted chickenpox from his grandchild. The client had to be hospitalized because of the seriousness of the condition. Which complication is the client at risk for developing secondary to chickenpox? 1. Deep vein thrombosis. 2. Varicella pneumonia. 3. Pericarditis. 4. Scarring of the skin.

Answer: 2 1. This is a complication of immobility, not specifically chickenpox. 2. Varicella-zoster (human herpesvirus 3) is the causative agent for chickenpox, and pneumonia is a potential complication in adults. 3. Pericarditis (inflammation of the sac surrounding the heart) is not a complication of chickenpox. 4. Scarring of the skin is an expected sequela of chickenpox, but it is not a complication. TEST-TAKING HINT: The question asks for a complication; therefore, option "4" could be ruled out because it is expected; if the test taker knows that chickenpox is caused by varicella-zoster, then the most obvious answer is option "2."

The nurse writes the client problem of "acute pain and itching secondary to bacterial skin lesions." Which interventions should be included in the care plan? Select all that apply. 1. Keep humidity at less than 20%. 2. Maintain a cool environment. 3. Use a mild soap for sensitive skin. 4. Keep lesions covered at all times. 5. Apply skin lotion after bathing.

Answer: 2, 3, 5 1. Humidity should be kept high, around 60%, to prevent the skin from drying. 2. Coolness deters itching. 3. Mild soaps contain no detergents, dyes, or fragrances to cause an increase in itching. 4. Lesions should be left open to air as much as possible; cloth rubbing the lesions is irritating. 5. Effective hydration of the stratum corneum prevents compromise of the barrier layer of the skin. TEST-TAKING HINT: "Select all that apply" questions require the test taker to make a determination for each option individually. Choosing one answer will not exclude another.

The nurse participating in a health fair is discussing malignant melanoma with a group of clients. Which information regarding the use of sunscreen should the nurse include? Select all that apply. 1. Sunscreen is needed only during the hottest hours of the day. 2. Check the expiration date to make sure the sunscreen is still effective. 3. Sunscreen does not help prevent skin cancer. 4. The higher the SPF number of sunscreen, the more UV rays it blocks. 5. Reapply sunscreen every 6 to 8 hours.

Answer: 2, 4 1. Sunscreen should be used whenever the client is going to be exposed to UV rays. 2. Most sunscreen is good for 2 to 3 years, but if it has been exposed to heat for long periods, it may be less effective (American Cancer Society, 2019). 3. Sunscreen blocks the absorption of UV rays, which, when allowed to penetrate the skin, cause damage to the layers of the skin. This, in turn, causes cellular changes, which, over time, can develop into skin cancer. 4. Sunscreen products range in numerical value from 4 to 1001; the higher the number of the sunscreen, the greater the UV protection. 5. Sunscreen should be reapplied at least every 2 hours to maintain protection, more often if swimming or sweating. TEST-TAKING HINT: Option "1" has the absolute word "only" and could be eliminated.

The nurse writes the problem "impaired skin integrity" for a client diagnosed with stage IV pressure injuries. Which interventions should be included in the plan of care? Select all that apply. 1. Turn the client every 3 to 4 hours. 2. Ask the dietitian to consult. 3. Have the client sign a consent for pictures of the wounds. 4. Obtain an order for a low air-loss bed. 5. Elevate the head of the bed at all times.

Answer: 2, 4 1. The client must be turned every 1 to 2 hours. 2. Clients diagnosed with pressure injuries usually are debilitated and have a poor nutritional base for healing. An increase in protein and vitamins is needed in the diet to promote healing. 3. Clients must sign consent if they are recognizable in the pictures. It is standard practice to document wounds by taking digital pictures and uploading the pictures into the EHR for reference by all concerned staff. In this instance, consent is not needed. 4. A client diagnosed with a stage IV pressure injury needs a higher level of pressure reduction than a normal hospital mattress can provide. 5. The head of the bed can be in any position of comfort for the client, but the head should not be elevated at "all" times because of the pressure applied to the lower body region. TEST-TAKING HINT: The test taker must notice time frames. Is 3 to 4 hours the correct time frame for turning a client diagnosed with impaired skin integrity? Option "5" can be eliminated because of the word "all."

The client is diagnosed with a viral infection and the HCP has prescribed an antiviral medication to be administered by weight. The client weighs 220 pounds and the order reads 10 mg per kilogram per day to be administered in equally divided doses every 6 hours. How many milligrams will be administered in one dose?

Answer: 250 mg per dose. First, determine the client's weight in kilograms; there are 2.2 pounds per kilogram, so: 220 pounds ÷ 2.2 = 100 kilograms Then, determine the total dosage to be given per day based on the HCP order of 10 mg per kilogram per day: 100 × 10 = 1,000 milligrams per day Then, determine how many doses are given in a day if a dose is to be given every 6 hours: 24 ÷ 6 = 4 doses Finally, determine how many milligrams per each dose to administer 1,000 mg in 24 hours: 1,000 ÷ 4 = 250 mg per dose TEST-TAKING HINT: Math problems frequently require multiple steps. The test taker should replace each number as the conversion is made. The test taker must know conversion factors and how to use the drop-down calculator on the computer.

The client comes to the clinic reporting the sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview? 1. "Do you live in an area where animals roam the street?" 2. "Have you been working in your garden lately?" 3. "Have you been deer hunting in the last week?" 4. "Do you use sunscreen when you are outside?"

Answer: 3 1. Animals roaming the streets is not as important to ask as if the client has been to an area where there is a likelihood of being exposed. 2. The client would most likely not be exposed to deer ticks while working in the garden. 3. Deer ticks (Ixodes scapularis) are responsible for the spread of Lyme disease, which is what this client is experiencing based on the clinical manifestations. 4. Sunscreen is important, but it will not protect the client from any type of insect bites. TEST-TAKING HINT: Option "4" could be eliminated as a possible answer if the test taker realized that the other three options all deal with some type of insect bite, which is stated in the stem of the question.

The client is diagnosed with acne vulgaris. Which psychosocial problem is a priority? 1. Impaired skin integrity. 2. Ineffective grieving. 3. Body image disturbance. 4. Knowledge deficit.

Answer: 3 1. Impaired skin integrity is a physiological problem, not a psychosocial problem. 2. The nurse does not know if the client is grieving over the acne. Do not read more into the question than is available. 3. Acne occurs on the face and neck. This is the first impression that people get when looking at the client; therefore, body image disturbance is the priority. 4. Knowledge deficit is appropriate for this client, but it does not have priority over body image. Acne can be devastating to a client's self-image. TEST-TAKING HINT: The test taker must remember to observe adjectives. "Psychosocial" is the keyword for answering this question.

The client is diagnosed with herpes simplex 2 and prescribed valacyclovir. Which instructions should the nurse teach? 1. This medication will prevent pregnancy and treat the virus. 2. This medication must be tapered when discontinuing the medication. 3. This medication will suppress symptoms but does not cure the disease. 4. This medication may cause the client's urine to turn orange.

Answer: 3 1. The antiviral medication valacyclovir (Valtrex) is not a birth control medication. 2. (Valtrex) is usually prescribed for a set amount of time and does not need to be tapered. 3. Valacyclovir (Valtrex) is an antiviral medication that suppresses the virus replication, but herpes is a retrovirus, which means it never dies as long as the host body is alive. 4. This medication does not cause the urine to turn orange. TEST-TAKING HINT: Medications are frequently advertised to the public; therefore, the nurse must know about medications that laypeople may be asking about.

The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first? 1. The 34-year-old client diagnosed with quadriplegia, unable to move his arms. 2. The older client diagnosed with a CVA and weakness on the right side. 3. The 78-year-old client diagnosed with pressure injuries and a temperature of 102.3°F. 4. The young adult who is unhappy with the care that was provided last shift.

Answer: 3 1. The client diagnosed with quadriplegia cannot move arms or legs. "Quad" means four, and none of the four extremities moves. This is expected for the client's problem. 2. Weakness on one side of the body is expected in clients diagnosed with a CVA (stroke). 3. The client has a fever indicating an infection. Clients diagnosed with pressure injuries frequently develop infections in the wounds, which can lead to further complications. 4. This is a psychological problem and should be addressed, but not before assessing the infection. TEST-TAKING HINT: The test taker must decide if the situation is expected for the disease process or if it is life-threatening. Physiological problems come before psychological problems, according to Maslow.

The nurse is applying mafenide acetate 10% cream to a client's lower extremity burn. Which assessment data would require immediate attention from the nurse? 1. The client reports pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and the sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PO2 98, PCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.

Answer: 3 1. The client should be premedicated with an analgesic because mafenide acetate (Sulfamylon), a sulfa antibiotic cream, causes severe burning pain for up to 20 minutes after application. 2. Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. Also, these electrolytes are WNL and would not require immediate intervention. 3. Mafenide acetate (Sulfamylon), a sulfa antibiotic cream, is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These arterial blood gases (ABGs) indicate metabolic acidosis and therefore require immediate intervention. 4. The client being able to perform range-of-motion exercises does not warrant immediate intervention; this is a very good result. TEST-TAKING HINT: "Require immediate attention" means that the nurse must intervene independently or notify another HCP. The test taker must know how to interpret ABGs, and even if the test taker is not familiar with the medication, metabolic acidosis requires intervention.

The client is being discharged after being in the burn unit for 6 weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.

Answer: 3 1. The client should resume previous activities gradually and should not stay home; the client should go out and begin to live again. 2. The client should be honest with self, family, and friends about needs, hopes, and fears. 3. The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time. 4. The client should feel free to discuss feelings with family, friends, and the therapist. TEST-TAKING HINT: Even if the test taker is not familiar with the disease process, there are certain interventions that go with any chronic problem, such as getting back to normal life as soon as possible and being independent, but also getting help when needed and not expecting too much too soon.

The RN is admitting an 88-year-old client diagnosed with a viral skin infection. Which nursing task could the nurse delegate to the UAP? 1. Measure and document the client's skin lesions. 2. Apply the antihistamine cream to the lesions. 3. Set up the isolation equipment for the client. 4. Determine if the client has prepared an advance directive.

Answer: 3 1. The nurse cannot delegate assessment, which is what measuring the lesions is doing, and the nurse must document the assessment. 2. This is a medication, and the nurse cannot delegate medication administration. 3. The nurse can delegate the setup of equipment to the assistant. 4. Determining if a client has an advance directive should not be delegated to the assistant because, if the client has questions, the nurse must provide factual information. TEST-TAKING HINT: The nurse must know which nursing tasks can be delegated; assessment, teaching, evaluating, and medication administration cannot be delegated to UAP.

The long-term care nurse has received the morning shift report. Which client should the nurse assess first? 1. The client with no bowel movement today. 2. The client needing an indwelling catheter changed. 3. The client diagnosed with periorbital skin lesions. 4. The client diagnosed with a stage I pressure injury.

Answer: 3 1. This client would not be a priority; elderly clients frequently think they need a daily bowel movement. 2. A catheter change would not be a priority. 3. Periorbital lesions may extend into the client's eyes, which is an ophthalmic emergency, especially if it is herpes zoster. 4. A stage I pressure injury requires changing the client's position, which can be delegated. TEST-TAKING HINT: If the test taker knows medical terminology, then "periorbital" (around the eye) would be a priority.

Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer after surgery to remove the lesion? 1. The client will express feelings of fear. 2. The client will ask questions about the diagnosis. 3. The client will state a diminished level of pain. 4. The client will demonstrate care of the operative site.

Answer: 3 1. This is a psychological goal, not a physiological goal. 2. This is a knowledge-deficit goal, not a physiological goal. 3. Pain is a physiological problem; this is an appropriate physiological goal. 4. This is a teaching goal, not a physiological goal. TEST-TAKING HINT: The test taker must read the question carefully to determine what the stem is asking. All of the goals are appropriate for the client diagnosed with skin cancer, but only one is a physiological goal.

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."

Answer: 3 1. This is the explanation for an autograft. 2. This is the description of a homograft. 3. A xenograft or heterograft consists of skin taken from animals, usually porcine. 4. This is "passing the buck"; the nurse can and should answer this question with factual information. TEST-TAKING HINT: The test taker should eliminate options to help determine the correct answers. Option "1" can be eliminated because skin from self would be auto-, not xeno-. Option "4" should be eliminated because the nurse should answer the question and not pass the buck.

The client with thick, crusty, yellow toenails is diagnosed with tinea unguium (onychomycosis) and asks the clinic nurse what happens if he can't afford to take the medication the physician prescribed. The nurse's response will be based on which scientific rationale? 1. The toes will become gangrenous and may have to be amputated. 2. Over-the-counter antifungal creams can be substituted for oral medication. 3. The toenail plate will separate and the entire toenail may be destroyed. 4. Take all the prescribed antibiotics or the infection may return.

Answer: 3 1. This sequela may occur for a client diagnosed with diabetes and a foot ulcer. 2. Oral antifungal agents must be taken for 12 weeks because the fungal infection is underneath the nail; topical medications would not reach the infection. 3. This is a condition of ringworm of the toenail. The nurse must tell the client that the toenail will fall off if the client does not take the medication, and it might fall off anyway. 4. This is not a bacterial infection; therefore, oral antibiotics will not be administered. It is a fungal infection and antifungal medication will be administered. TEST-TAKING HINT: Gangrene is usually a circulation problem, not a toenail problem; therefore, option "1" could be eliminated as a possible answer. Option "2" should be eliminated because nurses cannot prescribe or change physicians' orders. Of the two remaining options, only "3" has the word toenail in it; therefore, the test taker should select option "3" as the correct answer.

The nurse is assessing the client diagnosed with scabies. Which assessment technique would be most appropriate? 1. Gently palpate the affected area using sterile gloves. 2. Apply vinegar to the affected area to identify scabies. 3. Use a magnifying glass and a penlight to visualize the skin. 4. Obtain a Doppler to assess the movement of the mites.

Answer: 3 1. This technique will not help diagnose scabies. 2. Vinegar will not help visualize and identify scabies. 3. A magnifying glass and a penlight are held at an oblique angle to the skin while a search is done for small raised burrows, which indicate scabies. 4. A Doppler is used to obtain faint pulses, but it will not help find a mite, which causes scabies. TEST-TAKING HINT: The nurse must know about diagnostic equipment, and a Doppler is commonly used in clients diagnosed with a non-palpable pulse. Therefore, option "4" could be eliminated.

The older client is admitted from the long-term care facility diagnosed with congestive heart failure. The client reports severe itching on both hands and the nurse notes wavy, brown, threadlike lesions between the client's fingers. Which comorbid condition would the nurse suspect the client of having based on these assessment data? 1. Tinea capitis. 2. Herpes simplex 2. 3. Scabies. 4. Psoriasis.

Answer: 3 1. Tinea capitis is ringworm of the scalp, which does not support this client's clinical manifestations. 2. A herpes simplex 2 lesion is in the genital area. 3. Scabies is an infestation of the skin by the itch mite (Sarcoptes scabiei). The female burrows into the superficial layer of skin and burrows are found between the fingers and on the wrist. 4. Psoriasis is a chronic, noninfectious inflammatory disorder of the skin, which results in scales. TEST-TAKING HINT: The nurse should be familiar with medical terminology, which can often help rule out incorrect options. Capitus, for example, pertains to the head or scalp; therefore, option "1" could be eliminated as a possible answer.

The school nurse is preparing to teach a health promotion class for high school seniors. Which information regarding self-care should be included in the teaching? Select all that apply. 1. Apply a sunscreen with a protection factor of 10 or less when in the sun. 2. Try to stay out of the sun between 0300 and 0500 daily. 3. Perform a thorough skin check monthly. 4. Remember, caps and long sleeves do not help prevent skin cancer. 5. Wear sunglasses that block 99% to 100% of UVA and UVB rays.

Answer: 3, 5 1. The lower the SPF number of sunscreen, the less protection. A sunscreen of SPF 15 is a minimum. 2. Clients should avoid sunlight in the middle of the day, between 10 a.m. and 4 p.m, when the UV light is the strongest. "Between 0300 and 0500" refers to morning, the middle of the night. 3. The American Cancer Society (2019) recommends a monthly skin check using mirrors to identify any suspicious skin lesion for early detection. 4. Anything that prevents UV rays from reaching the skin helps to prevent skin cancer. Hats with a full brim are preferred to baseball caps, which leave the ears and back of the neck exposed. 5. Sunglasses should be worn to protect the skin around the eyes, and the eyes from UV exposure. Labels that say "UV absorption up to 400 nm" or "Meets ANSI UV Requirements" means the glasses block at least 99% of UV rays. Those labeled "cosmetic" block about 70% of UV rays. TEST-TAKING HINT: The test taker must notice time frames. In option "2," the use of "between 0300 and 0500" instead of "between 1500 and 1700" makes this option incorrect. In option "1" the number of the sunscreen makes this option wrong, and in option "4," the word "not" is an absolute word that could eliminate this option.

The registered nurse (RN) in a long-term care facility is teaching a group of new unlicensed assistive personnel (UAP). Which information regarding skincare should the nurse include in the teaching? Select all that apply. 1. Keep the skin moist by leaving the skin damp after the bath. 2. Do not rub any lotion into the skin. 3. Turn immobile clients at least every 2 hours. 4. Only the licensed nursing staff may care for the client's skin. 5. Avoid using talc powder or strong soaps.

Answer: 3, 5 1. The skin should be kept dry. The skin should be patted completely dry after each bath. 2. Older people have decreased moisture in the skin. Applying lotion restores moisture. 3. Clients should be turned at least every 1 to 2 hours to prevent pressure areas on the skin. 4. All employees in any health-care facility are responsible for providing care within their scope of services. 5. Talc powder and strong soaps dry the skin's natural oils and should not be used. TEST-TAKING HINT: Option "2" has an absolute "any" in it. The test taker can eliminate this as an answer on this basis. Option "4" has the absolute "only," so this option can be eliminated. Of the remaining options, option "3" can apply to all immobile clients.

The nurse is teaching a class on how to prevent Lyme disease. Which interventions should be included in the discussion? Select all that apply. 1. Instruct the clients to wear dark clothes when hunting. 2. Use a sunscreen of at least SPF 30 when outside. 3. Avoid dense undergrowth when in a wooded area. 4. Do not use any type of insect repellant when deer hunting. 5. Treat clothing and gear before going outdoors.

Answer: 3, 5 1. To help prevent deer tick bites, which spread Lyme disease, the individual should wear light-colored, tightly woven clothing with long pants and long-sleeved shirts. These allow the person to see the tick better. 2. Sunscreen will not help prevent the spread of Lyme disease. 3. Staying on paths and avoiding dense undergrowth will help the person keep away from tick-infested areas where the person is more likely to be bitten by a tick and perhaps subsequently develop Lyme disease. 4. Insect repellant should be used; there are special repellants, Environmental Protection Agency (EPA)-registered insect repellents, such as diethyltoluamide (DEET), that are used to help prevent Lyme disease. 5. Clothing and outdoor gear can be treated with 0.5% permethrin or bought already treated with 0.5% permethrin to protect from tick bites. TEST-TAKING HINT: The test taker should be able to rule out sunscreen as an answer because the stem says "disease" and sunscreen cannot prevent infectious disease. Not wearing insect repellant (option "4") would not be appropriate for any teaching except teaching about infants.

The client diagnosed with stage IV infected pressure injuries on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement? 1. "This surgery will create a skin flap to cover my wounds." 2. "This surgery will get all the old black tissue out of the wound so it can heal." 3. "The surgery is important to allow oxygen to get to the tissue for healing to occur." 4. "Stool will come out of an opening in my abdomen so it won't get in the sore."

Answer: 4 1. A skin flap to graft an open wound is not a fecal diversion. 2. This statement describes a débridement, not a fecal diversion. 3. Hyperbaric chambers are used to increase oxygenation to nonhealing wounds, but surgery does not increase oxygenation. 4. A fecal diversion is changing the normal exit of the stool from the body. A colostomy is created to keep stool from contaminating the wounds and causing infection. TEST-TAKING HINT: The word fecal means "stool." Only one option mentions anything to do with the stool.

The client diagnosed with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Ensure adequate peripheral circulation to both feet.

Answer: 4 1. An 18-gauge catheter with lactated Ringer's infusion should be initiated to maintain a urine output of at least 30 mL/hr. 2. Wounds should be covered with a clean, dry sheet. 3. The client should be transferred with adequate pain relief, which requires intravenous morphine. 4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes. TEST-TAKING HINT: Note the adjectives "22-gauge" and "moist." If the test taker is unsure of the correct answer, then the test taker should determine which system is affected and see if that will help determine the right answer. A client's extremities and a neurovascular assessment are similar; therefore, the test taker should select option "4."

The client is admitted to the medical floor diagnosed with cellulitis of the left arm. Which assessment data would warrant immediate intervention by the nurse? 1. The client has bilaterally weak radial pulses. 2. The client is able to move the left fingers. 3. The client has a CRT less than 3 seconds. 4. The client is unable to remove the wedding ring.

Answer: 4 1. As long as the client has bilateral pulses, there is no need for the nurse to intervene. 2. As long as the client is able to move the fingers, there is no need for the nurse to intervene. 3. A capillary refill time (CRT) less than 3 seconds is normal and would not require immediate intervention. 4. The client being unable to remove the wedding ring indicates that the arm is edematous, and the ring must be removed immediately or it may cause impaired circulation to the left ring finger. This is a dangerous situation. TEST-TAKING HINT: When the stem asks the test taker to identify data that warrant immediate intervention, the test taker must select the option that is abnormal for the disease process. All the options except "4" are normal neurovascular assessment data.

Which client is at the greatest risk for the development of skin cancer? 1. The African American male living in the northeast. 2. The older Hispanic female who immigrated from Mexico as a child. 3. The client with a family history of basal cell carcinoma. 4. The client with fair complexion and unable to tan.

Answer: 4 1. Darker-skinned individuals have a lower risk of developing skin cancer. It is living in the southwestern regions of the United States, where sun exposure is the greatest, that increases skin cancer risk. 2. Hispanic clients have more melanin in the skin than white clients, and moving from Mexico would have decreased the UV exposure. 3. A family history of malignant melanoma increases the risk of developing malignant melanoma. Basal cell carcinoma is directly related to sun exposure and does not have an increased familial risk. 4. Clients with very little melanin in the skin (fair-skinned) have an increased risk as a result of the UV damage to the underlying membranes. Damage to the underlying membranes never completely reverses itself; a lifetime of damage causes changes at the cellular level that can result in the development of cancer. TEST-TAKING HINT: If the test taker noticed the similarities in the clients in options "1" and "2"—darker skin and living in an area with less sun exposure or moving from an area with greater sun exposure to an area with less—the test taker could eliminate these two options. Based on skin color, the fair-skinned client would be most at risk.

The nurse is caring for a client diagnosed with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider (HCP)? 1. The client is reporting severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4°F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in 2 hours.

Answer: 4 1. Severe pain would be expected in a client diagnosed with these types of burns; therefore, it would not warrant notifying the HCP. 2. A pulse oximeter reading greater than 93% is WNL. Therefore, a 95% reading would not warrant notifying the HCP. 3. The client's vital signs show an elevated temperature, pulse, and respiration, along with low blood pressure, but these vital signs would not be unusual for a client diagnosed with severe burns. 4. Fluid and electrolyte balance is the priority for a client diagnosed with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25 mL/hr output would warrant immediate intervention. TEST-TAKING HINT: The test taker must select an answer that is not expected for the client's disease or condition when being asked which data warrant immediate nursing intervention.

The middle-aged client has had two lesions diagnosed as basal cell carcinoma removed. Which discharge instruction should the nurse include? 1. Teach the client that there is no more risk for cancer. 2. Refer the client to a prosthesis specialist for a prosthesis. 3. Instruct the client on how to apply sunscreen to the area. 4. Demonstrate care of the surgical site.

Answer: 4 1. The client should be taught to complete monthly skin checks to detect any future lesions. 2. Basal cell lesions grow slowly and do not metastasize until the lesion has become very large. Prostheses are usually not needed. 3. The area may need to have an antibiotic ointment, but sunscreen should not be applied until after the operative area has healed and then only when the client is going to be in the sun. 4. On discharge, all clients should receive instructions in the care of surgical incisions. TEST-TAKING HINT: If the test taker did not know the specific information regarding this type of cancer surgery, then choosing an answer that is appropriate for all surgeries is a good option.

The clinic nurse is preparing to administer medications. Which safety precautions should the nurse employ when administering the client's medications? Diagnosis: Basal Cell Carcinoma of the Lip Allergies: Caine Drugs - 5-fluorouracil cream apply topically to lip 1. Keep the head of the bed or chair elevated for 30 minutes after the application. 2. Teach the client not to eat solid foods for 24 hours after the medication is applied. 3. Have the client expose the area to sunlight for 30 minutes after the application. 4. Wear unsterile gloves when applying the 5-fluorouracil cream to the client's lip.

Answer: 4 1. The cream should not be affected by the position of the head. 2. Once the 5-fluorouracil cream has absorbed into the skin, the client can eat solid or liquid foods. 3. Exposure to sunlight is the most common reason for developing skin cancer; sun exposure is not recommended. Clients receiving 5-fluorouracil orally or intravenously can become photosensitive. 4. The nurse should protect against coming into contact with the 5-fluorouracil cream. TEST-TAKING HINT: The test taker should remember basic medication administration guidelines. Unsterile gloves are required whenever a nurse is applying topical medications to prevent personal exposure to the medication.

The nurse is presenting an in-service to participants in a local health fair. Which information regarding the development of skin cancers should the nurse teach? 1. The fairer the skin, the less the risk of developing skin cancer. 2. Eating a diet high in fiber helps to minimize the risk of skin cancer development. 3. Sun exposure at a beach is less dangerous than at a stadium. 4. The participants should avoid sun exposure in the middle of the day.

Answer: 4 1. The fairer the skin, the greater the risk of developing skin cancer. 2. Dietary fiber does not impact the development of skin cancer. 3. Sun exposure is not less dangerous at a beach—the exposure is basically the same. It depends on the length of time and amount of exposure to the UV rays. 4. The middle of the day, between 10 a.m. and 4 p.m., is when the UV rays are the strongest. UV rays are also stronger in the spring and summer, at higher elevations, and locations closest to the equator. TEST-TAKING HINT: The test taker must be aware of basic principles such as when the sun is hottest, resulting in greatest skin exposure, and that people at a beach usually are exposing more skin to the damaging rays of the sun.

The client is reporting a burning, stabbing pain that radiates around the left rib cage area. The nurse cannot find any type of skin abnormality. Which action should the nurse implement? 1. Transfer the client to the ED for a cardiac work-up. 2. Inform the client that the nurse can't see anything. 3. Administer a nonnarcotic analgesic to the client. 4. Ask if the client ever had chickenpox.

Answer: 4 1. The left rib cage area is not considered an area for revealing cardiac problems. The client diagnosed with a cardiac problem would have chest pain radiating to the left arm, sweating, and nausea. 2. This negates the client's reports and does not address the client's concerns. The nurse should always further assess when the client is in pain. 3. The nurse should not administer pain medication unless the cause of the pain is known. The client is reporting severe pain, and Tylenol (a nonnarcotic) will not be effective. 4. The client's description of the pain suggests shingles. Shingles is caused by herpes zoster, which is the same virus as varicella-zoster, which causes chickenpox. This virus is a retrovirus that never dies; it becomes dormant and lives in the body along nerve pathways. During times of stress, it can erupt as herpes zoster or shingles. The pain usually occurs before the eruption of the vesicles. TEST-TAKING HINT: If the test taker does not know the answer, then the test taker should apply the nursing process. Option "4" is the only option involving assessment, which is the first part of the nursing process.

What is the scientific rationale for placing lift pads under an immobile client? 1. The pads will absorb any urinary incontinence and contain stool. 2. The pads will prevent the client from being diaphoretic. 3. The pads will keep the staff from workplace injuries such as a pulled muscle. 4. The pads will help prevent friction shearing when repositioning the client.

Answer: 4 1. The pads will absorb moisture and will protect the bed, but they also will keep the moisture next to the client's skin, which increases the risk of skin breakdown. 2. The pads are made with plastic liners, which tend to contain heat next to the client's body, thereby increasing diaphoresis. 3. The pads are a help to lift the client but are not used to prevent workplace injuries. To prevent workplace injuries, the staff must practice good body mechanics. 4. Lifting the client with a "lift" pad rather than pulling the client against the sheets helps to prevent skin damage from friction shearing. TEST-TAKING HINT: The stem asks for the rationale for using "lift" pads. Lifting a client involves repositioning the client (option "4"). None of the other options mentions any kind of repositioning.

Which client would most likely be at risk for the development of a carbuncle? 1. The young male just beginning to shave. 2. The female with a fair complexion. 3. The male with a daily gym workout routine. 4. The female diagnosed with diabetes mellitus.

Answer: 4 1. This client is not at increased risk for developing a carbuncle. 2. This client is not at increased risk for developing a carbuncle. 3. This client is not at increased risk for developing a carbuncle. 4. A carbuncle is an abscess of the skin and subcutaneous tissue and is an extension of a furuncle. These are more likely to occur in clients diagnosed with underlying systemic diseases such as diabetes, hematologic malignances, and immunosuppression. TEST-TAKING HINT: If the definition of a carbuncle was not known, the test taker could look at the options and note that only one has a disease process, which might be the best choice for the correct answer.

The wound care nurse documented a client's pressure injury on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client's pressure injury is getting worse? 1. The skin is not broken and is 2.5 × 3.5 cm with erythema that does not blanch. 2. There is a 3.2 × 4.1 cm blister that is red and drains occasionally. 3. The skin covering the coccyx is intact, but the client reports pain in the area. 4. The coccyx wound extends to the subcutaneous layer and there is drainage.

Answer: 4 1. This describes a stage I pressure injury, which would be an improvement of the client's wound. 2. This is a stage II pressure injury and is not a significant change in the wound. 3. This implies that the skin has healed and is not at stage I. 4. This is a stage III pressure injury and is a worsening of the client's condition. TEST-TAKING HINT: The test taker could look at the description in the stem and then at the descriptions in the options. Only one option appears to have a more involved skin condition.

The client diagnosed with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal? 1. The client will refrain from scratching the skin. 2. The client will maintain intact skin integrity. 3. The client will have relief from itching. 4. The client will not develop a secondary bacterial infection.

Answer: 4 1. This would be a short-term goal, but it is unrealistic to expect a client not to scratch when experiencing severe itching. 2. The client currently has lesions; therefore, skin integrity is already compromised. The keyword is "maintain." 3. Relief of itching is a short-term goal for this client. For a long-term goal, the nurse needs to recognize potential complications. 4. A major complication of pruritus (itching) is the development of a bacterial skin infection, which is secondary to the client scratching and allowing bacteria from the dirty hands or nails to enter compromised tissue. TEST-TAKING HINT: The test taker must recognize what clinical manifestations the client is experiencing. Lesions are open wounds; therefore, option "2" could be eliminated even if the test taker did not know what the word "pruritus" means. Furthermore, the test taker must look at adjectives; the question asks for long-term goals, and the test taker should realize immediate behavior change (refrain from scratching) and pain relief are short-term goals.

The school nurse is discussing how to prevent tinea cruris with the football players. Which intervention should the nurse implement? 1. Instruct the football players to wear tight, snug-fitting jockstraps. 2. Explain the importance of wearing white socks. 3. Teach the football players not to share brushes or combs. 4. Discuss the need to dry the groin area thoroughly after bathing.

Answer: 4 1. To prevent tinea cruris (jock itch), the football players should avoid wearing nylon underwear, tight-fitting clothing, and wet bathing suits. 2. This would be appropriate advice for tinea pedis (athlete's foot). 3. This would be appropriate advice to help prevent lice. 4. Tinea cruris (jock itch) results from a fungal infection in warm, moist areas of the body. When such an infection occurs in the groin area, it is called tinea cruris. TEST-TAKING HINT: All the options discuss prevention of something; therefore, the test taker must know about disease processes. Test-taking hints do not substitute for studying and understanding the material. Remember that perfect test scores are few and far between.