SDL integumentary

The client is prescribed silver sulfadiazine (Silvadene), a topical antimicrobial agent, for a partial-thickness burn to the back. Which information should the nurse discuss concerning this medication? 1. Encourage the client to drink 3000 mL of water. 2. Discuss the need to eat foods high in protein. 3. Teach the client how to test the urine for ketones. 4. Instruct to change the dressing twice a day.

1. Encourage the client to drink 3000 mL of water.

Which nursing interventions should be included for the client who has 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 invasive lines once a week. 5. Administer antibiotics as prescribed. 6. Use the same sterile glove for wound care of the left upper & right upper extremities to avoid auto-contamination

1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 5. Administer antibiotics as prescribed.

•The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 1. Removing all clothing, including gloves and shoes 2. Determining the antidote for the chemical and placing the antidote on the burn site 3. Leaving all clothing in place until the client is brought to the emergency department 4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

1. Removing all clothing, including gloves and shoes

The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select all that apply. 1."I have to avoid excessive exposure to sunlight." 2."My dark skin color predisposes me to skin cancer." 3."I am at higher risk for skin cancer because my mother had one." 4."I am at higher risk for skin cancer because I am 20 years old." 5."I am immune to skin cancer because I work as a pest control exterminator." 6. "I am at higher risk for skin cancer because I am a 75 year old fair skinned and work in construction."

1."I have to avoid excessive exposure to sunlight." 3."I am at higher risk for skin cancer because my mother had one." 6. "I am at higher risk for skin cancer because I am a 75 year old fair skinned and work in construction."

The nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply. 1. Turn the client every three (3) to four (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.

2. Ask the dietitian to consult. 4. Obtain an order for a low air-loss bed.

The client with a partial-thickness burn to the entire right leg who is being treated with silver sulfadiazine (Silvadene), a sulfonamide antibacterial agent, develops leukopenia. Which action would the nurse suspect that the HCP would prescribe? 1. Discontinue the Silvadene ointment immediately. 2. Continue administering the Silvadene ointment. 3. Administer aminoglycoside antibiotics intravenously. 4. Administer a hydrocortisone cream to the burned area.

2. Continue administering the Silvadene ointment.

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position

3. Immobilization of the affected leg

The home care nurse visits an order client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measures should the nurse recommend for the client to alleviate this discomfort? 1. Run a humidifier at home 2. Apply astringents to the skin twice daily 3. Keep nails trimmed and apply emollients to the skin after bathing 4. Take baths twice daily using a dilute solution of alcohol and water

3. Keep nails trimmed and apply emollients to the skin after bathing

The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which priority intervention should the nurse implement to help prevent pressure ulcers in a client who is on strict bed rest? 1. Keep the skin moist by leaving the skin damp after the bath. 2. Do not rub any lotion into the skin. 3. Turn the client at least every two hours. 4. Use pressure-relieving devices such as waterbeds. 5. Provide adequate skin care for the client. 6. Ensure sufficient nutritional intake.

3. Turn the client at least every two hours.

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What should the nurse include in client teaching to maximize the effects of the treatment? 1.Rub the application into the skin. 2.Place the area under a heat lamp for 20 minutes. 3.Apply a dry sterile dressing over the affected area. 4.Cover the application with a warm, moist dressing and an occlusive outer wrap.

4.Cover the application with a warm, moist dressing and an occlusive outer wrap.

A male client is admitted with flash burns to the anterior surface of both arms. anterior trunk, and anterior surface of both legs.. Using the rule of nines, what total percentage of the client's skin surface is burned? (Enter number value only. If round...)

45 Add 4.5+4.5+18+9+9 = 45

A nurse is making initial rounds at the beginning of the shift and notice that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit? A. 10% dextrose in water. B. 5% dextrose in water. C. 5% dextrose in normal saline. D. 5% dextrose in lactated Ringer solution. E. 50% Dextrose in water solution

A. 10% dextrose in water.

The nurse is caring for a client with lower extremity cellulitis who is receiving antibiotics. What is the best way for the nurse to evaluate the effectiveness of the treatment? A. Observe for signs and symptoms of inflammation B. Note any thickening scarring ridge of the toe C. Assess the pedal pulses on Rt and Lt feet D. Assess the client's capillary refill

A. Observe for signs and symptoms of inflammation

A client with full thickness burns of the lower extremities is recovering from bilateral escharotomies. Which of the following interventions would be appropriate for the client at this time? A. Provide wound care as prescribed B. Keep the sites open to air C. Restrict fluids D. Assess heart rate and lung sounds.

A. Provide wound care as prescribed

The nurse assesses a client being treated for Herpes Zoster (shingles). In evaluating the effectiveness of the treatment, which assessments should the nurse include? (select all that apply) A.Functional ability B.Heart sounds C.Bowel sounds D.Skin integrity E.Pain scale

A.Functional ability D.Skin integrity E.Pain scale

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? A. Superficial B. Full-thickness C. Deep partial-thickness D. Partial-thickness superficial

B. Full-thickness

A patient presented to the hospital with history of burn of 60% full thickness, bone pain, and muscle weakness. Which nursing intervention is the most important? A. Encourage active range of motion B. Instruct the use of muscle strength exercise C. Teach supplement of vitamin D D. Explain the need for skin exposure to sun light without sun screen

C. Teach supplement of vitamin D

The nurse is preparing a client with full-thickness burns on the upper right leg for an escharotomy. Which statement indicates the client understands the procedure? A. All burned skin will be removed to prevent infection B. The upper layer of the burned skin will be removed to prevent blister formation C. The thick leathery crust of the skin will be removed to promote circulation and healing D. The burned site is being prepared for skin transplantation

C. The thick leathery crust of the skin will be removed to promote circulation and healing

A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? A. 1200 mL of 5% dextrose in water solution B. 2400 mL of 0.45% normal saline solution C. 4800 mL of 0.9% normal saline solution D. 9600 mL of lactated Ringer's solution

D. 9600 mL of lactated Ringer's solution

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels

D. Elevated hematocrit levels

A client uses Triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema and purulent exudate at the site. What action should the nurse implement? A.Advise the client to apply plastic wrap over the ointment to promote healing B.Instruct the client to continue the ointment until all erythema is relieved C.Explain that the client needs to complete all prescribed doses of medication D.Schedule an appointment for the client to see the healthcare provider

D.Schedule an appointment for the client to see the healthcare provider

A pt suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this pt's plan of care? a. continuous cardiac monitoring b. perform passive range of motion c. evaluate LOC d. assess lung sounds q4h

a. continuous cardiac monitoring