PNU 133 PrepU Passpoint Integumentary Disorders

A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should monitor the client for which adverse reaction to this drug?

Ototoxicity

A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."

A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema?

Administer tepid baths, and use moisturizers immediately after the bath.

The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client?

Avoid exposure to sun.

A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply.

Be sure to wear shower shoes when using a public shower. Change socks at least once a day. Keep skin clean and dry.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft

While assessing a client, a nurse notes a stage I pressure ulcer on the client's left hip. How should the nurse report this finding?

Document the size, extent, and location of the wound in the client's medical record.

Which intervention has the highest priority when providing skin care to a bedridden client?

Keeping the skin clean and dry without using harsh soaps

When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply.

Monitor the skin for breakdown daily during client's bath. Keep skin clean and dry to prevent breakdown. Turn and reposition the client every two hours.

Which action by the nurse displays client advocacy during a skin assessment?

Ensuring client privacy by pulling the curtain closed

Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale?

Excessive use can have adverse effects, such as skin atrophy and fragility.

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Which additional manifestation should the nurse assess for to help identify necrotizing fasciitis?

Increased pain intensity

The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply.

Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others.

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. Encourage the client to eat a well-balanced diet.

The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

A parent brings a child to the health care provider's office because the child reports pain, redness, and tenderness of the left index finger. The child is diagnosed with paronychia. Which organism is the most likely cause of this superficial abscess of the cuticle?

Staphylococcus species

A home health nurse is evaluating a client's risk of contracting herpes zoster. Which client is most at risk for developing herpes zoster?

a 76-year-old client taking immunosuppressant medication

A postoperative client has just been admitted to a unit from the postanesthesia care unit (PACU). When should the nurse change the dressing for the first time?

after the surgeon changes the first dressing and provides the written orders

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

cancer of the cervix.

The nurse is gathering data from several children in the clinic with reports of diarrhea. Which child would be at greatest risk for giardiasis?

child that attends group day care

A nurse is caring for a client who was admitted to the burn unit after suffering burns from a house fire. During the acute phase of a burn, the nurse should collect data on which topic?

circulatory status

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact

A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize?

lean meats and low-fat milk

A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. How should the nurse document the findings?

petechiae

The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis?

pruritic papules, pustules, and linear burrows of the finger and toe webs

The nurse is gathering data from a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which observation most likely supports this finding?

purulent drainage on a soiled wound dressing

The nurse observes a ring-shaped rash that has a red raised border and a clearer center on the upper arm. The client asks the nurse what kind of rash it is. What is the best response by the nurse?

tinea corporis

Discharge instructions for a child with atopic dermatitis include keeping the fingernails cut short. Which rationale should the nurse give for this intervention?

to reduce breaks in skin from scratching that may lead to secondary bacterial infections

The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing?

wash hands thoroughly

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should:

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.

A client is prescribed methotrexate 25 mg by mouth as a single weekly dose. The pharmacy dispenses 2.5-mg scored tablets. How many tablets should the nurse instruct the client to consume to achieve the prescribed dose? Record your answer using a whole number.

10

While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"All family members will need to be treated."

A client understands what resources are available to help him perform wound care at home when he states the following:

"Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need."

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client?

"Cover the area when in direct sunlight."

When teaching a client with intertrigo about prescribed skin care measures, the nurse should include which important instruction to prevent Candida albicans overgrowth?

"Never apply cornstarch to the affected areas."

The nurse is caring for a client receiving photochemotherapy treatment. Which statement by the client indicates understanding?

"On the day of treatment, I need to stay out of the sun."

Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)?

"They're benign and usually fade in adult life."

A 22 lb (10 kg) child is diagnosed with Kawasaki disease and started on gamma globulin therapy. The health care provider orders an IV infusion of gamma globulin, 2 g/kg, to run over 12 hours. How many grams should the nurse give the client? Record your answer using a whole number.

20

A licensed practical nurse is assisting a triage nurse in the emergency department admit a client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned?

36

The nurse is working in a pediatric emergency department. Which client would the nurse see first?

5-year-old client with orbital cellulitis

A nurse is assisting with the development of a care plan for a client with impaired wound healing. Which client would be a risk factor for this diagnosis? Select all that apply.

60-year-old client with impaired mobility secondary to a CVA 75-year-old client with poorly controlled diabetes

The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavax vaccine for the prevention of shingles?

62-year-old client that had a mild case of shingles 4 years previously