Pressure Ulcers & Prevention
A nurse is caring for several clients. Which of the following clients is most prone to skin infections?
A. A 55-year-old client taking an ACE inhibitor
B. A 20-year-old client with a closed tibia fracture
C. A 60-year-old client with gastritis
D. A 35-year-old client receiving chemotherapy
D. Clients who are immunocompromised are prone to infection.
Which of the following information regarding the transmission of lice would the nurse identify as a myth?
A. Lice can be spread by sharing of hats, caps, and combs.
B. Lice can jump from one individual to another.
C. Lice need to be removed from the hair with a fine comb.
D. Lice can be seen without magnification.
ANS: B
The nurse is correct to identify that lice cannot jump from one individual to another. Direct contact is needed for transmission. The other options are correct.
A client who plays football for a local high school is seeing the health care provider for treatment of athlete's foot. What does the nurse anticipate the health care provider to order?
A. Antibiotic
B. Antifungal
C. Antiviral
D. Antineoplastic
B. Antifungal
A nurse assessing the wound healing of a client documents that the wound is well approximated and forms a clean, straight line with little loss of tissue. This wound healed by:
A. Primary intention.
B. Secondary intention.
C. Tertiary intention.
D. Dehiscence.
A. Primary intention
A nurse is caring for a client with a chronic wound and is discussing smoking cessation. The client does not understand how smoking may impact wound healing. Which of the following would be the best nurse response?
A. Smoking causes you to cough frequently and the wound might get infected by sputum.
B. Nicotine causes tar to build up in the wound and it will impair healing.
C. Smoking is bad and you should stop right away.
D. Nicotine causes vasoconstriction so your wound might not get enough blood flow to heal.
ANS: D
Nicotine causes vasoconstriction and decreases the blood flow to the wound which can impair wound healing.
An older adult client, who is bedridden, is admitted to the unit because of a pressure injury. During assessment, the nurse finds that the ulcer extends into the dermis. At what stage should the nurse document this injury?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B. Stage II
A nurse is caring for a client who complains of a painful, blistery rash that has occurred on the left side of the chest. The nurse identifies that this is most likely which of the following?
A. Shingles
B. Cellulitis
C. Yeast infection
D. Impetigo
A. Shingles appear as a painful, blistering rash, and usually only on one side of the body or face.
A nurse is caring for a client who has a prescription for diphenhydramine to relieve pruritus. The client asks the nurse how he can minimize the daytime sedation he is experiencing. Which of the following responses should the nurse make?
A. "Gradually decrease the dose once tolerance to the effect is reached."
B. "Distribute the doses evenly throughout the day."
C. "Take the daily dose at bedtime."
D. "Take the medication with meals."
C. "Take the daily dose at bedtime."
Taking the dose at bedtime will allow the client to obtain the benefit of maximum relief of symptoms and rest without itching.
A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The skin on the knees is intact, but they have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?
A. Contusion
B. Abrasion
C. Puncture
D. Avulsion
A. Contusion
A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)
A. Blood pressure
B. Bowel sounds
C. Level of consciousness
D. Urine output
E. Platelet count
A, C, & D.
Blood pressure is a good measure of fluid volume status. Bowel sounds are not related to fluid resuscitation. Level of consciousness is an indicator of perfusion and can be used to evaluate fluid resuscitation along with vital signs. Urine output is a good measure of fluid volume status. Platelet count is not an indicator of fluid volume.
A nurse is contributing to the plan of care for a client who has a stage 3 pressure ulcer on his heel. Which of the following information should the nurse include in the plan?
A. Keep the ulcer bed dry.
B. Clean the wound bed with hydrogen peroxide.
C. Provide the client a diet high in vitamin C.
D. Reposition the client at least every 4 hr.
C. Provide the client a diet high in vitamin C.
Which term describes a fungal infection of the body?
A. Tinea capitis
B. Tinea corporis
C. Tinea cruris
D. Tinea pedis
B. Tinea corporis
Which client is most likely to benefit from treatment with topical nystatin?
A. a client with candidiasis growing in skin folds
B. a client whose acne has not responded to topical antibiotics
C. a toddler diagnosed with impetigo
D. a school-aged child with pruritis secondary to chicken pox infection
A. a client with candidiasis growing in skin folds
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
A. The wound will take up to 3 weeks to heal.
B. Pain management will be a challenge.
C. Skin grafting will be necessary.
D. Ligaments, tendons, muscles, and bone are not involved.
ANS: C
Rationale: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.
A nurse is aware of the varied therapeutic applications for hot and cold application. Which clients may benefit the most from the application of heat?
A. a client whose oral temperature is 38.6° C (101.5° F)
B. a client whose injured knee is visibly swollen
C. a client who is experiencing epistaxis (nosebleed)
D. a client who is experiencing back spasms
D. a client who is experiencing back spasms
A nurse is planning preventive care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?
A. Massage the client’s bony prominences.
B. Keep the head of the bed elevated at least 30 degrees.
C. Reposition the client at least every 2 hr.
D. Keep the client’s skin moist.
C. Reposition the client at least every 2 hr.
A nurse is discussing moisture-related skin conditions with a nursing student. Which of the following clients is most likely to have a pressure or moisture related skin condition?
A. A client in the intensive care unit in a coma
B. A client who is post-op day one for an appendectomy
C. A client who has recently delivered a baby
D. A client in the emergency department for asthma
ANS: A
Rationale: Clients hospitalized in the ICU have higher rates of moisture-associated skin damage.
The health care provider prescribes methotrexate for a 28-year-old woman with severe psoriasis. When obtaining a health history from the patient, the most important information for the nurse to communicate to the health care provider is that the patient has
a. a history of infectious mononucleosis as a teenager.
b. a family history of age-related macular degeneration of the retina.
c. been trying to get pregnant
d. been using large doses of vitamins and health foods to treat the psoriasis.
Correct Answer: C
Rationale: Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy
A nurse is caring for a 70-year-old client who has a pressure injury in the coccyx area. The nurse identifies that which of the following factors associated with aging may impact the ability for the ulcer to heal?
A. Elevated hemoglobin
B. Low bone density
C. Decreased protein level
D. Increased muscle mass
ANS: C
Rationale: Protein assists with wound healing and older adults often have low protein levels.
A client's wound is a thin, watery, pink-tinged substance. The nurse correctly describes the drainage as:
A. Sanguineous
B. Serosanguineous
C. Serous
D. Purulent
B. Serosanguineous
A nurse is caring for a client with a pressure injury. Which of the following should the nurse recognize as a priority in the plan of care?
A. Keeping the wound clean and noninfected
B. Application of a negative pressure wound care device
C. Client education on wound prevention
D. Promoting a high carbohydrate, low protein diet
A. Keeping the wound clean and noninfected are vital to wound healing.
A nurse is caring for several medical surgical clients. Which of the following should the nurse see first?
A. A client with chronic psoriasis
B. A client with a new scalp laceration
C. A client with a vaginal yeast infection
D. A client with cellulitis of the hand
B. A client with a new scalp laceration can bleed, causing a circulation problem if it is not stopped.
When planning care for a client with herpes zoster, what medication, if administered within the first 24 hours of the initial eruption, can arrest this virus?
A. Deltasone (Prednisone)
B. Vancomycin
C. Triamcinolone cream (Kenalog)
D. Acyclovir (Zovirax)
D. Acyclovir (Zovirax)
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?
A. removing dead or infected tissue to promote wound healing
B. stimulating the wound bed to promote the growth of granulation tissue
C. removing purulent drainage from the wound bed in order to accurately assess it
D. removing excess drainage and wet tissue to prevent maceration of surrounding skin
A. removing dead or infected tissue to promote wound healing. Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
C. Include intact skin at the wound edges in the culture.
D. Swab an area of skin away from the wound to identify normal flora.
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.