Nursing 1400 ATI Quiz Week 5 Practice Questions with Answers, Exams of Nursing

Download Nursing 1400 ATI Quiz Week 5 Practice Questions with Answers and more Exams Nursing in PDF only on Docsity! Nursing 1400 ATI QUIZ Week 5 Practice questions with answers 1. A nurse on a surgical unit is caring for four clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? a. Partial-thickness burns i. A partial-thickness burn heals by spontaneous re- epithelialization. Since it involves the uppermost layers of the dermis, scarring can be minimal or extensive depending on the depth of the burn b. Stage III pressure ulcer i. Stage II pressure ulcer will heal by secondary intention c. Surgical incision i. With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of wound that heals by primary intention d. Dehisced sternal wound i. A dehisced sternal wound can either close by secondary or tertiary intention 2. A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that, in addition to protein, which of the following nutrients promotes wound healing? a. Vitamin B1 i. Vitamin B1 promotes functioning of the nervous system; however, it does not specifically promote wound healing b. Calcium i. Calcium aids in blood clotting and muscle contraction; however, it does not specifically promote wound healing c. Vitamin C i. A diet high in protein and vitamin C is recommended because these nutrients promote wound healing d. Potassium i. Potassium is necessary for muscle activity and fluid balance; however, it does not specifically promote wound healing 3. A nurse is providing teaching to a client who is wheelchair-bound and his caregiver about ways to reduce the risk of pressure ulcer formation. Which of the following instructions should the nurse include? a. “Move between the bed and the wheelchair once every 2 hours.” i. The nurse should instruct wheelchair-bound clients at risk for pressure ulcer formation to change position at least once every hour b. “Make sure that your caregiver massages your skin daily.” i. The nurse should instruct the client and his caregiver to avoid massaging the skin, especially over bony prominences, because it can further traumatize fragile tissues c. “Use a rubber ring when sitting at the bedside.” i. The nurse should instruct the client and his caregiver to avoid using a rubber ring for sitting because it reduces circulation to the client’s skin d. “Shift your weight in the wheelchair every 15 minutes.” i. This response addresses the safety issue of pressure ulcer risk. Pressure ulcers are most likely to develop if the client does not shift position frequently to relieve pressure i. The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin. b. Collagen i. The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing. c. Calcium alginate i. The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing. d. Proteolytic enzyme i. The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing. 7. A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? a. Obtain the prescribed irrigation solution i. The nurse should obtain the prescribed irrigation solution prior to performing the procedure; however, there is another action the nurse should take first. b. Don PPE i. The nurse should don personal protective equipment prior to performing the procedure to prevent exposure to blood or bodily fluids from the client’s wound; however, there is another action the nurse should take first. c. Check the client’s pain level i. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client’s level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to wound care will decrease pain and increase comfort. d. Place a waterproof pad under the client’s extremity i. The nurse should place a waterproof pad under the client’s extremity to protect the linens from moisture and contamination during the irrigation; however, there is another action the nurse should take first. 8. A nurse is caring for a client who has peripheral vascular disease (PVD) and ulcers on the toes. Which of the following findings of PVD is a risk factor for ulceration of the extremities? a. Insufficient skin care i. Insufficient skin care is not the cause of ulcers on the toes of a client who has PVD. However, poor skin care can lead to skin infections and breakdown. b. Dehydration i. Dehydration is not the cause of ulcerations of the client's toes. However, dehydration can delay wound healing. c. Immobility i. Immobility can cause pressure ulcers if the client is not turned frequently. However, ulcerations of the client's toes are not caused by immobility. Peer Comparison A3% B1% C8% ✔D88% Difficulty level: Mode rate d. Impaired circulation i. Prolonged arterial insufficiency from PVD can contribute to the formation of ulcerations on the client's toes. Severe arterial disease is identified through an assessment of the quality of the client's posterior tibial pulses by comparing the pulses in both feet. 9. A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? a. Incontinence i. Incontinence is a parameter on the Norton scale, not the Braden scale b. Mental state i. Mental state is a parameter on the Norton scale, not on the Braden scale c. Nutrition i. Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers. d. General physical condition i. General physical condition is a parameter on the Norton scale, not on the Braden scale 10. A nurse is providing discharge teaching about wound care to a client who has a leg wound. Which of the following pieces of information should the nurse include in the teaching? (SATA) a. Use cotton balls to clean the infected areas b. "I'll wash my hands before I remove the old dressing and again before putting on the new one." i. It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings. c. "I'll need to take a pain pill 30 minutes before I change the dressing." i. This might be a good practice if the dressing changes are painful; however, this statement does not address medical asepsis, only pain management. d. "I'll wear sterile gloves when I apply the new dressing." i. Clean gloves and dressings are standard for clients at home. If sterile dressings are necessary, a home health care nurse should perform the dressing changes. 13. A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? a. Wear sterile gloves when collecting the specimen i. The nurse should wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab. b. Cleanse the wound with 0.9% sodium chloride irrigation i. The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate. c. Allow the collection swab to absorb old exudate i. Pooled drainage can collect microorganisms that are not the pathogens causing the wound infection. d. Rotate the collection swab over the edges of the wound i. The nurse should rotate the swab back and forth over clean areas in the base of the wound to collect the pathogens causing the wound infection. The edges of the wound can harbor superficial microorganisms from the skin that are not infecting the wound. 14. A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? a. “Use an exfoliating cleanser.” i. Abrasive skin agents such as exfoliating cleansers can worsen acne and cause trauma to the skin. Only gentle skin cleansers should be used. b. “Keep hair of f your forehead.” i. Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne. c. “Take tetracycline after meals.” i. Tetracycline should be taken on an empty stomach to improve the absorption of the medication d. “Squeeze acne lesions as they appear.” i. The nurse should instruct the client not to squeeze or pick acne lesions. Squeezing acne lesions ruptures glands and causes sebum to spread into the skin, which increases inflammation 15. A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA) a. Bradycardia i. Histamine is a potent vasodilator; therefore, a client who is going into anaphylaxis will exhibit tachycardia. b. Nausea i. A common gastrointestinal response to excessive histamine release is nausea. c. Hypertension i. Histamine is a potent vasodilator, so the child will exhibit hypotension. d. Urticaria i. A common skin manifestation of excessive histamine release is hives, also known as urticaria. e. Stridor i. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor. 16. A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? a. Elevate the client’s feet and legs i. This client is at risk of anaphylactic shock, and elevating the client’s lower extremities helps maintain an adequate blood pressure; however, there is another action the nurse should take first. b. Administer epinephrine i. This client is at risk of anaphylactic shock, and elevating the client’s lower extremities helps maintain an adequate blood pressure; however, there is another action the nurse should take first. c. Infuse 0.9% sodium chloride i. The client is at risk of progression to anaphylaxis, and infusing isotonic IV fluids can help hydrate the client and maintain blood pressure; however, there is another action that the nurse should take first. d. Stop the medication infusion i. The nurse should remind the client that anorexia, nausea, and vomiting are gastrointestinal adverse effects of the medication. 19. A nurse is caring for a client who is taking diphenhydramine for allergies. The client reports, "I feel sleepy during the day." Which of the following responses should the nurse make? a. “You will find that all antihistamines cause sedation.” i. Diphenhydramine is a first-generation antihistamine and has a common adverse effect of sedation. b. “You should avoid taking the antihistamine with food.” i. The nurse should tell the client to take diphenhydramine with food to decrease gastrointestinal irritation that can cause nausea and vomiting. c. “The effects of sedation will occur with each dose.” i. Diphenhydramine is a first-generation antihistamine and has a common adverse effect of sedation. However, sedative effects subside after a few days of taking the antihistamine. d. “You should try antihistamines with non-sedative effects.” i. The nurse should tell the client to try second-generation antihistamines that have no sedative effect, as these are large molecules with low lipid solubility that cannot cross the blood- brain barrier. Diphenhydramine is a first-generation antihistamine and has a common adverse effect of sedation. 20. A nurse is monitoring the laboratory values of a male client who has leukemia and is receiving weekly chemotherapy with methotrexate via IV infusion. Which of the following laboratory values should the nurse report to the provider? a. BUN 18 mg/dL i. The nurse should monitor the BUN of a client who is taking methotrexate because the medication can cause kidney injury. This client’s BUN is within the expected reference range and does not need to be reported to the provider at this time. b. Platelets 78,000/mm3 i. The nurse should monitor the platelet count of a client who is taking methotrexate because the medication can cause thrombocytopenia. This client’s platelet count is very low and puts the client at risk of severe bleeding. The nurse should report this finding promptly to the provider. c. Hemoglobin 14.2 g/dL i. The nurse should monitor the hemoglobin of a client who is taking methotrexate because the medication can cause bone marrow suppression. This client’s hemoglobin is within the expected reference range and does not need to be reported to the provider at this time. d. Aspartate aminotransferase (AST) 35 units/L i. The nurse should monitor the AST of a client who is taking methotrexate because the medication can cause liver damage. This client’s AST is within the expected reference range and does not need to be reported to the provider at this time. 21. A nurse is reviewing the medical record of a client with rheumatoid arthritis who has a prescription for infliximab. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. Psoriatic arthritis i. Psoriatic arthritis is a chronic disease characterized by inflammation of the skin and joints. TNF medications such as infliximab suppress inflammation by suppressing TNF, which can reduce the manifestations of psoriatic arthritis. b. Hepatitis B virus i. The nurse should identify that infliximab is a tumor necrosis factor (TNF) antibody medication that is used to reduce the disease manifestations and to delay disease progression. Infliximab has immunosuppressant properties that can increase the risk of infection. Clients who have an active or chronic infection such as hepatitis B virus should not take infliximab. c. Ulcerative colitis i. Ulcerative colitis is an inflammatory bowel disease that affects the innermost lining of the colon. Treatment includes surgery and medication therapy, which can include TNF medications. d. Ankylosing spondylitis i. Ankylosing spondylitis is a form of arthritis that primarily affects the spine, causing severe, chronic pain and discomfort. Infliximab is a TNF medication that can limit the progression of arthritis and decrease inflammation. Evolve – Assessment of the Integumentary System 1. The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system? a. Diuretic b. Corticosteroid 1. Corticosteroids can have unwanted integumentary side effects such as telangiectasia. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics. c. Benzodiazepine d. Calcium channel blocker 2. An adolescent is brought to the clinic by a parent for treatment of acne. What should the nurse assess the patient for to support the existence of acne? a. Ulcers b. Wheals the organs beneath the skin. d. Percussion of the skin on the back 7. The patient has diffuse distribution of moles on the body and the nurse is preparing the patient for a punch biopsy of one of the moles. What is the benefit of doing a punch biopsy for this patient? a. It is used for a superficial lesion. b. It provides a full- thickness of skin. 1. The punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy is used for a superficial lesion or when only a small sample is needed for diagnostic purposes. An excisional biopsy is used when a good cosmetic result is desired. An incisional biopsy is a wedge-shaped incision made in a lesion that is too large for an excisional biopsy. It is useful when a larger specimen is needed than a shave or punch biopsy can provide. c. It is used for good cosmetic results. d. It is used because the lesion is too large to remove. 8. When assessing an older adult patient, the nurse observed general wrinkles, sagging breasts, and tenting of the skin; gray hair; and thick brittle toenails. What age-related changes can cause these changes in the integumentary system? a. Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails b. Decreased extracellular water, surface lipids, and sebaceous gland activity; decreased scalp oil; and decreased circulation c. Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply 1. The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching d. Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation 9. A nurse is obtaining a health history from a patient with a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient? a. “Is your sleep interrupted by severe episodes of itching at night?” b. “Have you noticed any changes in the way sores or wounds heal?” 1. A patient with diabetes is more susceptible to poor wound healing because of the macrovascular and microvascular changes that occur in diabetes. Poor circulation, especially in the lower extremities, increases the risk for poor wound healing. A patient with diabetes is at increased risk for infection because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes. c. “Do you have any skin lesions that have changed in size or shape?” d. “What changes if any have you noticed in your skin, hair, and nails?” 10. An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration? a. The skin color over the nose and ears has a blue tint. b. The skin of the extremities is warm and dry to touch. c. Pressing the skin over the ankles causes pitting for 10 seconds. d. Pinching the skin under the clavicle causes tenting for 10 seconds. 1. Skin turgor is good when skin moves easily when lifted and immediately returns to its original position when released (no tenting). A loss of skin turgor occurs with dehydration and aging that will result in tenting. With hypovolemia, expected skin changes are cool without edema or central cyanosis. 11. The nurse performs a physical assessment on a dark-skinned African American patient who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient? a. Lips d. Apply a layer of medication that is just thick enough to ensure coverage. Vitamin D in canned salmon, sardines, fortified dairy, and eggs d. nurse ld be a. b. c. d. c. Avoid covering skin areas where a topical medication has been applied. 1. Topical medication should be applied in a thin film to clean skin and spread evenly in a downward motion in the direction of hair growth. Medications may be applied directly on to secondary dressings, and regions with medications may be covered. A tongue blade is not normally used for the application of a thin coat. 3. The patient has bleeding gums and purpura. What vitamin in which foods should be encouraged as a nutritional aid to these problems? a. Vitamin B7 in liver, cauliflower, salmon, carrots b. Vitamin A in sweet potatoes, carrots, dark leafy greens c. Vitamin C in peppers, dark leafy greens, broccoli, and kiwi 4. Th e sh ou 1. An absence of vitamin C causes symptoms of scurvy, including petechiae, bleeding gums, and purpura. A deficiency of vitamin B7 (biotin) may result in rashes and alopecia. Vitamins A is needed for wound healing. Vitamin D is needed for bone and body health. is t ching the residents of an independent living facility about preventing skin infections and infestations. What included in the teaching? Use cool compresses if an infection occurs. Oral antibiotics will be needed for any skin changes. Antiviral agents will be needed to prevent outbreaks. Inspect skin for changes when bathing with mild soap. 1. Persons living in independent living facilities are usually older, which means their skin does not need cleaning with hot water and vigorous scrubbing or as often as a younger person. Mild a. soap (e.g., Ivory) should be used to avoid loss of protection from neutralization of the skin’s surface. The skin should be inspected for changes with bathing. Cool compresses are used with ringworm or stings for the anti- inflammatory effect. Oral antibiotics are used for Lyme disease from ticks. Antiviral agents are used for viral infections but not to prevent outbreaks. 5. The patient with a stage IV pressure ulcer on the coccyx will need a skin graft to close the wound. Which postoperative care should the nurse expect to use to facilitate healing? No straining of the grafted site 1. Straining or stretching of the grafted site must be avoided to allow the graft to be vascularized and fixed to the new site for healing. The wound may or may not be exposed to air depending on the type of graft, and the donor site will be covered with a protective dressing to prevent further damage. Soft tissue expansion and pressure dressings will not be used after this wound’s skin graft. b. The wound will be exposed to air. c. Soft tissue expansion will be done daily. d. The pressure dressing will not be removed. 6. A patient informs the nurse that they are afraid to use the treatment recommended for psoriasis. What is the best response by the nurse? a. “You will only know if you try it and see.” b. “You may need to get counseling to help you cope.” c. “No treatment is medically necessary, but it can be removed.” d. “Topical, light therapy, and systemic medications are now available.” d. “Tell me about your activities the past 2 to 7 days.” a. 1. Treatment of psoriasis usually involves a combination of strategies, including topical treatments; phototherapy; and/or systemic medications, including biologic drugs. Telling her that she will only know if she tries or that she may need counseling is denying the patient’s concern. Psoriasis is treated to manage the disease as the patient may have a weakened immune system and be at risk for cardiovascular disease. 7. The nurse assesses small, firm, reddened raised lesions with flat, rough patches on a patient that are causing intense pruritus. What question should the nurse next ask the patient? a. “Have you started any new medications?” b. “Do you have a history of seasonal allergies?” c. “Have you had any lesions such as this before?” 1. The patient’s lesions are papules and plaques characteristic of contact dermatitis. The nurse should ask the patient about activities over the past 2 to 7 days to identify potential allergens because contact dermatitis has a delayed onset. Even if an offending agent is not identified, the nurse can provide patient teaching about managing the pruritus and preventing infection by decreasing scratching. Seasonal allergies and new medications are more likely to cause urticaria than papules and plaque. The nurse should also ask about pruritic rashes in the past to determine potential illnesses that can cause dermatologic manifestations. 8. A patient admitted with heart failure is also diagnosed with herpes zoster and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that individual? The dietitian wears a mask when entering the patient’s room. 1. Herpes zoster, commonly known as shingles, is spread by contact with fluid draining from the vesicles (not by coughing, sneezing, hands after changing the dressing to avoid infection. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. 1. Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing. e. Notify the health care provider of redness, swelling, and increased drainage. 2. A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? a. Increased platelet count b. Increased blood urea nitrogen c. Increased number of band neutrophils 1. The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented. d. Increased number of segmented myelocytes 3. A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? a. Sero us b. Purulent 1. Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response. c. Fibrinous d. Catarrhal 4. A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? a. Frequent examination of the character and quantity of exudate b. Monitoring for signs and symptoms of local or systemic infections c. Assessment of the patient’s circulation distal to the location of the dressing 1. Any compression dressing requires vigilant assessment of the circulation distal to the dressing site because tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient’s mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain. d. Assessment of the range of motion of the ankle and the patient’s activity tolerance 5. A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? a. Pain level b. Intake and output 1. Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient’s overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient. c. Oxygen saturation d. Level of consciousness 6. A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue d. Evaluate the area later to see if it is better. 11. An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? a. Dress it with an absorbent dressing for exudate. b. Handle the wound gently and let it dry out to heal. c. Debride the nonviable, eschar tissue to allow healing. 1. With a black wound, the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and re- epithelializing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement. d. Use negative-pressure wound (vacuum) therapy to facilitate healing. 12. The nurse assesses impaired skin integrity in this patient. How will the nurse document this? a. Stage I b. Stag e II c. Stage III 1. Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage II ulcers are partial thickness with a red-pink wound bed. Stage IV ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle. d. Stage IV 13. The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? a. Fever and chills b. Increased blood pressure c. Increased respiratory rate d. General malaise and fatigue 1. An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or “just not feeling well.” 14. The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? a. b. c. 1. Serosanguineous drainage is frequently seen postoperatively and is composed of RBCs and serous fluid so it is a semiclear pink drainage. Serous drainage is a thin, watery drainage. Hemorrhagic drainage is bloody drainage. Purulent drainage consists of WBCs, microorganisms, and other debris that signal an infection. d. 19. Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? a. Keep the pressure ulcer clean and dry. b. Maintain protein intake of at least 1.25 g/kg/day. 1. Adequate protein intake (between 1.25 and 1.50 g/kg/day) is needed to promote healing of pressure ulcers. Hydrogen peroxide is cytotoxic and should not be used to clean pressure ulcers. A 30-mL syringe with a 19-gauge needle will provide optimal pressure (4 to 15 psi) without causing tissue trauma or damage. The pressure ulcer should be kept moist to aid in healing. c. Use a 10-mL syringe to irrigate the pressure ulcer. d. Irrigate the pressure ulcer with hydrogen peroxide. 20. Which patient is most at risk for the development of a pressure ulcer? a. An older patient who is septic, bedridden, and incontinent 1. Individuals at risk for the development of pressure ulcers include those who are older, incontinent, bed or wheelchair bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes mellitus, elevated body temperature, immobility, and anemia. b. An obese woman with leukemia who is receiving chemotherapy c. A middle-aged thin man in a halo cast after a motor vehicle accident d. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis 21. On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer? a. Category/Stage III b. Category/ Stage IV c. Unstageable 1. To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged. d. Suspected deep tissue injury 22. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? a. Bind er b. Ice bag 1. An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin care and moisture barriers must also be used with frequent position changes to assist in reducing the risk for pressure ulcers. 28. What does the Braden Scale evaluate? a. Skin integrity at bony prominences, including any wounds b.Risk factors that place the patient at risk for skin breakdown 1. The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds. c. The amount of repositioning that the patient can tolerate d. The factors that place the patient at risk for poor healing 29. Which of the following are measures to reduce tissue damage from shear (SATA)? a. Use a transfer device (e.g., transfer board) b. Have head of bed elevated when transferring patient c. Have head of bed flat when re-positioning patients d. Raise head of bed 60 degrees when patient positioned supine e. Raise head of bed 30 degrees when patient positioned supine 1. A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed to be elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position will cause patient to slide down, causing shear. 30. After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions (SATA)? a. Notify the surgeon b. Allow the area to be exposed to air until all drainage has stopped c. Place several cold packs over the area, protecting the skin around the wound d. Cover the area with sterile saline-soaked towels and immediately 1. If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. e. Cover the area with sterile gauze and apply an abdominal binder 31. Which of the following describes a hydrocolloid dressing? a. A seaweed derivative that is highly abortive b. Premoistened gauze placed over a granulating wound c. A debriding enzyme that is used to remove necrotic tissue d. A dressing that forms a gel that interacts with the wound surface 1. A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing. 32. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound (SATA)? a. Collection of wound drainage b. Provides support to abdominal tissues when coughing or walking c. Reduction of abdominal swelling d. Reduction of stress on the abdominal incision 1. A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement. e. Stimulation of peristalsis (return of bowel function) from direct pressure Test Bank – Integumentary System 1. Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse? a. Reports a history of allergic rashes i. Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient. because the swabbing is not usually painful. The patch test is done to determine whether a patient is allergic to specific testing material, not for obtaining fungal specimens. d. Local anesthetic, syringe, and intradermal needle 6. During assessment of the patient’s skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions? a. Confluent b. Zosteriform c. Genera lized d. Symmetric i. The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions. 7. A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles i. Lichenification is likely to occur in areas where the patient scratches the skin frequently. Lichenification results in thickening of the skin with accentuated normal skin markings. Vitiligo is the complete absence of melanin in the skin. Keloids are hypertrophied scars. Yellowish-brown skin indicates jaundice. Vitiligo, keloids, and jaundice do not usually occur as a result of scratching the skin. c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles 8. Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Several dry, scaly patches on the face b. Numerous varicosities noted on both legs c. Dilation of small blood vessels on the face d. Petechiae present on the chest and abdomen i. Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient’s health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action. 9. Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (SATA)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. i. Skills such as administration of patch testing and sterile dressing technique are included in LPN/LVN education and scope of practice. Obtaining a health history and patient education require more critical thinking and registered nurse (RN) level education and scope of practice. d. Teach a patient about site care after a punch biopsy of an upper arm lesion. e. Explain potassium hydroxide testing to a patient with a superficial skin infection. Test Bank – Integumentary Problems 1. Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 8 to 10 for adequate protection. b. Water resistant sunscreens will provide good protection when swimming. c. Increase sun exposure by no more than 10 minutes a day to avoid skin damage. d. Try to stay out of the sun between the hours of 10 AM and 2 PM (regular time). i. The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant sunscreens still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased. 2. Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. i. The patient should stay out of the sun. If that is not possible, teach them to wear sunscreen when taking medications that can cause photosensitivity. The other statements are not accurate. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication. 3. A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a biopsy. i. Because the appearance of the lesion suggests actinic keratosis or possible squamous cell carcinoma (SCC), the appropriate 8. A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Cleanse the skin carefully with an antiseptic soap. b. Shield any unaffected areas with lead-lined drapes. c. Have the patient use protective eyewear while receiving PUVA. i. The eyes should be shielded from UV light (UVL) during and after PUVA therapy to prevent the development of cataracts. The patient should be taught about the effects of UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum jelly are not used to prevent skin damage. d. Apply petroleum jelly to the areas surrounding the psoriatic lesions. 9. Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. i. Warm water and moisturizing soap will avoid overdrying the skin. Because older patients have dryer skin, daily bathing and shampooing are not necessary and may dry the skin unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the skin is still damp to seal moisture in. d. Use antibacterial soaps when bathing to avoid infection. 10. What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Soak the dressing in sterile normal saline. c. Apply antibiotic ointment over the wound. d. Wash hands and properly dispose of soiled dressings. i. Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Sterile glove and sterile saline use during wound care will not necessarily prevent spread of infection. Applying antibiotic ointment will treat the bacteria but not necessarily prevent the spread of infection. 11. The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient uses Neosporin ointment on minor cuts or abrasions. i. Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient. c. The patient adds oilated oatmeal (Aveeno) to the bath water every day. d. The patient takes diphenhydramine (Benadryl) at night if itching occurs. 12. The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse’s best action? a. Teach the patient about the treatment of fungal infection. b. Discuss the use of drying agents to minimize infection risk. c. Instruct the patient about the use of mild soap to clean skinfolds. d. Ask the patient about type 2 diabetes or if there is a family history of it. i. The presence of acanthosis nigricans in skinfolds suggests either having type 2 diabetes or being at an increased risk for it. The description of the patient’s skin does not indicate problems with fungal infection, poor hygiene, or the need to dry the skinfolds better. 13. When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse’s best action? a. Instruct the patient about the importance of nutrition in skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. i. The patient has clinical manifestations that could be caused by systemic problems such as malnutrition or hypothyroidism, so further diagnostic evaluation is indicated. Patient teaching about nutrition, addressing the patient’s dry skin, and referral to a podiatrist may also be needed, but the priority is to rule out underlying disease that may be causing these manifestations. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin. 14. A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. “After I apply the medication, I can go ahead and get dressed as usual.” b. “I will need to minimize my time in the sun while I am using the Elidel.” c. “I will rub the medication gently onto the skin every morning and night.” d. “If the medication burns when I apply it, I will wipe it of f and call the doctor.” i. The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective. information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis. 20. There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 38-year old with a 7-mm nevus on the face that has recently become darker i. The description of the lesion is consistent with possible malignant melanoma. This patient should be assessed as soon as possible by the health care provider. Itching is common after using topical fluorouracil and redness is an expected finding a few days after a chemical peel. Skin tags are common, benign lesions after midlife. b. 62-year-old with multiple small, soft, pedunculated papules in both axillary areas c. 42-year-old with complaints of itching after using topical fluorouracil on the nose d. 50-year-old with concerns about skin redness after having a chemical peel 3 days ago 21. A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (SATA)? a. Cool, wet cloths or dressings can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over- the-counter (OTC) antihistamine can reduce scratching. i. Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry. Test Bank – Inflammation and Wound Healing 1. The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. i. The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally. c. Notify the health care provider. d. Assess the wound every 2 hours. 2. A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. i. The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage. 3. A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature i. The patient’s complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature. d. Decreasing blood pressure 4. A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient’s oral temperature again in 4 hours. i. Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient’s health care provider or to use a cooling b. Stag e II c. Stage III i. A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues. d. Stage IV 10. A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patient’s bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patient’s position at least every 2 hours. i. The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching, but the most important instruction is to change the patient’s position at least every 2 hours. 11. The nurse will perform which action when doing a wet-to-dry dressing change on a patient’s stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change. i. Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing. 12. A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30- mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half- strength peroxide. i. Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate. 13. A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. i. Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase what is the nurse’s highest priority? a. Maintaining the patient’s blood glucose within a normal range i. Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing. b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily 19. Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level i. With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing. b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound 20. After the home health nurse teaches a patient’s family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting. i. Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care. 21. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient’s plan of care. In which order should the nurse perform the following actions? a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol). i. The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last. Med-Surg Success 1. The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize? a. Keep the skin moist by leaving the skin damp after the bath. i. The skin should be kept dry. The skin should be patted completely dry after each bath. b. Do not rub any lotion into the skin. i. Elderly people have decreased moisture in the skin. Applying lotion restores moisture. c. Turn clients who are immobile at least every two (2) hours. i. Clients should be turned at least every one (1) to two (2) hours to prevent pressure areas on the skin. d. Only the licensed nursing staff may care for the client’s skin. i. All employees in any health-care facility are responsible for providing care within their scope of services. 2. The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority? c. The pads will keep the staff from workplace injuries such as a pulled muscle. d. The pads will help prevent friction shearing when repositioning the client. 5. The wound care nurse documented a client’s pressure ulcers on admission as 3.3 cm × 4 cm stage II on the coccyx. Which information would alert the nurse that the client’s pressure ulcer is getting worse? a. The skin is not broken and is 2.5 cm × 3.5 cm with erythema that does not blanch. b. There is a 3.2-cm × 4.1-cm blister that is red and drains occasionally. c. The skin covering the coccyx is intact but the client complains of pain in the area. d. The coccyx wound extends to the subcutaneous layer and there is drainage. 6. The nurse and an unlicensed assistive personnel (UAP) on a medical floor are caring for clients who are elderly and immobile. Which action by the UAP warrants immediate intervention by the nurse? a. The UAP elevates the head of the bed of a client who can feed himself with minimal assistance. b. The UAP asks to take a meal break before turning the clients at the two (2)-hour time limit. c. The UAP restocks the rooms that need unsterile gloves before clocking out for the shift. d. The UAP mixes Thick-It into the glass of water for a client who has difficulty swallowing. 7. The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first? a. The 34-year-old client who is quadriplegic and cannot move his arms. b. The elderly client diagnosed with a CVA who is weak on the right side. c. The 78-year-old client with pressure ulcers who has a temperature of 102.3 F. d. The young adult who is unhappy with the care that was provided last shift. 8. 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? a. Use a pillow to keep the heels of f the bed when supine. b. Order a low air-loss therapy bed immediately. c. Prepare to insert a nasogastric feeding tube. d. Order an occupational therapy consult for strength training. 9. 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? (SATA) a. Turn the client every three (3) to four (4) hours. b. Ask the dietitian to consult. c. Have the client sign a consent for pictures of the wounds. d. Obtain an order for a low air-loss bed. e. Elevate the head of the bed at all times. 10. 42. The nurse observes the unlicensed assistive personnel (UAP) squeezing the “blackheads” on an elderly client. Which action should the nurse implement first? a. Notify the unit manager of witnessing this activity. b. Instruct the assistant to stop this behavior. c. Demonstrate the correct way to care for the skin. d. Complete an incident report regarding the action 11. 43. The client is diagnosed with acne vulgaris. Which psychosocial problem is priority? a. Impaired skin integrity. b. Ineffective grieving.