Medical Surgical Nursing - Integumentary DIsorders

The nurse is developing a program about skin cancer prevention for a community group. Which information should be included in the program? Select all that apply. Purchase sunscreen containing benzophenones to block UVA and UVB rays. Use sunscreen with a minimum of 30 sun protection factor (SPF). Obtain genetic screening to identify risk of melanoma. Apply sunscreen only on sunny days, especially between 1000 and 1400. Have a pigmented lesion biopsied by shaving if it looks suspicious.

Purchase sunscreen containing benzophenones to block UVA and UVB rays. Use sunscreen with a minimum of 30 sun protection factor (SPF).

A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure? "Minimize sun exposure from 10 a.m. to noon, when the sun is strongest." "Use a sunscreen with a sun protection factor of 6 or higher." "Apply sunscreen even on overcast days." "When at the beach, sit in the shade to prevent sunburn."

"Apply sunscreen even on overcast days."

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding? "I will limit my intake of red meat to once a week." "I'll make sure that I keep the site covered at all times." "Increase in redness of the ulcer means better blood flow." "I'll eat plenty of fruits and vegetables."

"I'll eat plenty of fruits and vegetables."

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? "I should begin to use an antibacterial soap a few days before my surgical procedure." "On the morning of the surgery, I can shave my surgical area at home to save time." "On the morning of surgery, I won't use lotions or cosmetics." "I'll shower before coming to the hospital on the day of the surgery."

"On the morning of the surgery, I can shave my surgical area at home to save time."

The client asks the nurse why the wound vacuum assisted device is necessary. What is the nurse's best response? "This device will increase the amount of wound drainage." "This device will decrease tissue granulation." "This device will gently pull the wound edges together." "This device will provide positive pressure to stimulate healing."

"This device will gently pull the wound edges together."

A client returns from the operating room with a partial-thickness skin graft on the left arm. The donor tissue was taken from their left hip. In planning the client's immediate postoperative care, which interventions would the nurse include? Select all that apply. Change the dressing on the graft site every 8 hours. Elevate the left arm and provide complete rest of the grafted area. Administer pain medication every 4 hours as ordered for pain in the donor site. Perform range-of-motion (ROM) exercises to the left arm every 4 hours. Monitor the pulse in the left arm every 4 hours. Encourage the client to ambulate as desired on the first postoperative day.

Elevate the left arm and provide complete rest of the grafted area. Administer pain medication every 4 hours as ordered for pain in the donor site. Monitor the pulse in the left arm every 4 hours.

While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects squamous cell carcinoma. actinic keratoses. melanoma. basal cell carcinoma.

melanoma.

A nurse is caring for a client with a pressure ulcer. The nurse understands that the purpose of a hydrocolloid dressing application is to: be highly absorptive and prevent infection. promote granulation of the wound. remove necrotic tissue by using enzymes. form a paste that interacts with the surface of the wound.

remove necrotic tissue by using enzymes.

When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch? chicken breast, salad, and iced tea roast beef sandwich, milkshake, and cottage cheese hamburger, orange, and coffee pasta salad, carrots, and milk

roast beef sandwich, milkshake, and cottage cheese

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. Over the past few weeks, the client has been spending less time in the wheelchair. During the appointment, the nurse notes that the client is not using a cushion and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen? Call the family contact to ask about how the treatments have been done. Ask the client to explain the treatment regimen. Explain pressure ulcer development in terms that the client understands. Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

Ask the client to explain the treatment regimen.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Turn and reposition the client every 4 hours. Massage lotion over bony prominences when turning. Develop a written, individual turning schedule. Use two people when sliding the client up in bed.

Develop a written, individual turning schedule.

The nurse is preparing information for a community health fair. Which information should the nurse include to promote healthy skin? Drink an adequate amount of water. Use a water temperature of 125oF (52oC) for bathing. Apply body lotion that contains a sun protection factor of 10. Limit sun exposure to 30 minutes in the afternoon.

Drink an adequate amount of water.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. Reposition the client every 2 hours. Perform range-of-motion exercises. Use commercial soaps to keep the skin dry. Tuck bed covers tightly into the foot of the bed. Encourage the client to eat a well-balanced diet.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

A client presents at the health care provider's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? Select all that apply. The disease is actively contagious only when the lesions are open. Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. The most commonly infected areas are the scalp and neck. Severe itching of the affected areas, especially at night, is a common finding. Only the infected individual needs to use the prescribed medication. All of the client's linens and clothing should immediately be washed in hot water.

Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. Severe itching of the affected areas, especially at night, is a common finding. All of the client's linens and clothing should immediately be washed in hot water

A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted to the emergency department with lesions on the hands. The health care provider prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply. Take the prescribed antibiotics for 60 days. Avoid contact with other members of the family during the treatment period. Wear a mask for 60 days. Expect the skin lesions to clear up within 1 to 2 weeks. Wash hands frequently.

Take the prescribed antibiotics for 60 days. Expect the skin lesions to clear up within 1 to 2 weeks.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what prescription should the nurse request from the health care provider? furosemide fresh frozen plasma IV rate increase dextrose 5%

furosemide

A nurse assesses a client who was admitted to the emergency department with a thermal burn to the right arm and upper chest. Which assessment requires immediate action? thirst singed hair on the upper chest hoarse voice bright red skin with small blisters on the right arm

hoarse voice

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? complaints of intense thirst moderate to severe pain urine output of 70 ml the first hour hoarseness of the voice

hoarseness of the voice

A school-age client is experiencing severe itching in both hands that is worse at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. Which nursing diagnosis should the nurse use to plan care for this client? acute pain impaired skin integrity sleep deprivation risk for infection

impaired skin integrity

The nurse is caring for a client who has deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, there will be a fluid shift from the: intracellular to extracellular compartment. extracellular to intravascular compartment. interstitial to the intracellular compartment. intravascular to the interstitial compartment.

intravascular to the interstitial compartment.

An autograft is taken from the client's left leg. The nurse should care for the donor site by: covering it with an occlusive dry dressing. keeping the site clean and dry. applying a pressure dressing. wrapping the extremity with an elastic bandage.

keeping the site clean and dry.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? albumin dextrose 5% in water (D5W) lactated Ringer's solution normal saline solution with 20 mEq of potassium per 1,000 ml

lactated Ringer's solution

In a client who has been burned, which medication should the nurse expect to use to prevent infection? gamma benzene hexachloride diazepam mafenide meperidine

mafenide

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? stage I pressure ulcer stage II pressure ulcer stage III pressure ulcer stage IV pressure ulcer

stage II pressure ulcer

The nurse is performing triage in the emergency department. Which client should be seen first? the client with flank pain radiating to the groin the client who has an open fracture of his radius the client with burns to the chest and neck with singed nasal hair a primipara who is 39 weeks pregnant having contractions every 15 minutes

the client with burns to the chest and neck with singed nasal hair

The rate at which IV fluids are infused is based on the burn client's: lean muscle mass and body surface area (BSA) burned. total body weight and BSA burned. total BSA and BSA burned. height and weight and BSA burned.

total body weight and BSA burned.

A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body? 9% 18% 27% 36%

18% According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

Using the Parkland Formula, calculate the hourly rate of fluid replacement with lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. Record your answer using a whole number.

750 mL When calculating fluid replacement, only the burned portion of the TBSA is used to calculate fluid volume; thus the nurse should administer the solution at 750 mL/hour. Lactated Ringer's solution 4 mL X weight in kg X TBSA; half given over the first 8 hours and half given over the next 16 hours. 4 X 75 X 40 = 12,000 12,000/8 X 1/2 = 750 mL.

The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions, which areas have provided effective outcomes in preventing pressure ulcers? Select all that apply. Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. When turning the client, slide and avoid lifting. Avoid raising the head of the bed more than 90°. Turn and reposition the client every 1 to 2 hours unless contraindicated. If the client uses a wheelchair, sit on a rubber or plastic doughnut. Use positioning devices to position the client and increase comfort.

Clean the skin with warm water and a mild cleaning agent, then apply a moisturizer. Turn and reposition the client every 1 to 2 hours unless contraindicated. Use positioning devices to position the client and increase comfort.

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan? placing mitts on the client's hands administering systemic antibiotics as ordered applying topical antibiotics as ordered continuing to administer antibiotics for 21 days as ordered

administering systemic antibiotics as ordered

When should the nurse initiate rehabilitation plans for the client who has severe burns? immediately after the burn has occurred after the client's circulatory status has been stabilized after grafting of the burn wounds has occurred after the client's pain has been eliminated

after the client's circulatory status has been stabilized

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first? Prepare an incident report. Prepare a disciplinary warning for the nursing assistant. Document the findings. Contact the shift supervisor.

Document the findings.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? partial pressure of arterial oxygen (PaO2) value of 80 mm Hg urine output of 20 ml/hour white pulmonary secretions rectal temperature of 100.6° F (38° C)

urine output of 20 ml/hour

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? stage I pressure ulcer stage II pressure ulcer stage III pressure ulcer stage IV pressure ulcer

stage II pressure ulcer

Sudoriferous glands secrete which type of substance? sweat oil hormones cerumen

sweat