Passpoint Integumentary | When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer?

Passpoint Integumentary When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note

which factor that can most alter tissue tolerance and lead to the development of a pressure ulcer?

You Selected:

 exposure to moisture

Correct response:

 exposure to moisture

Explanation:

Remediation:

Question 2 See full question

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes

that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as

far as the dermis. What should the nurse note on the medical record?

You Selected:

 stage I pressure ulcer

Correct response:

 stage II pressure ulcer

Explanation:

Remediation:

Question 3 See full question

Which factor is most important for the nurse to consider when determining the angle at which to insert

the needle for a subcutaneous injection?

You Selected:

 length of the needle

Correct response:

 amount of subcutaneous tissue

Explanation:

Remediation:

Question 4 See full question

During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the nurse should

monitor hourly which information that will be used to determine the IV infusion rate?

You Selected:

 urine output

Correct response:

 urine output

Explanation:

Remediation:

Question 5 See full question

A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which instruction

should the nurse include in her teaching plan?

You Selected:

 Use a topical skin moisturizer daily.

Correct response:

 Use a topical skin moisturizer daily.

Explanation:

Remediation:

Question 6 See full question

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days

later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching

because these exercises may:

You Selected:

 dislodge the autografts.

Correct response:

 dislodge the autografts.

Explanation:

Remediation:

Question 7 See full question

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid

does the nurse plan to administer first?

You Selected:

 Lactated Ringer's solution

Correct response:

 Lactated Ringer's solution

Explanation:

Remediation:

Question 8 See full question

The nurse is caring for an immune compromised client with a fungal infection of the scalp. What

recommendation should the nurse make to prevent future problems?

You Selected:

 Wash hair with a dandruff-preventing shampoo.

Correct response:

 Avoid sharing combs and brushes.

Explanation:

Remediation:

Question 9 See full question

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy

that was not turned off while working on it. What is the priority nursing intervention in the acute phase

of care?

You Selected:

 A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac

dysrhythmias.

Correct response:

 A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac

dysrhythmias.

Explanation:

Remediation:

Question 10 See full question

A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after

moving the client to another room. The client's roommate asks the nurse for information about the

client. What should the nurse say?

You Selected:

 "I'm sorry, but I can't share confidential information."

Correct response:

 "I'm sorry, but I can't share confidential information."

Question 1 See full question

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

You Selected:

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

Correct response:

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

Explanation:

Remediation:

Question 2 See full question

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?

You Selected:

 Contact

Correct response:

 Contact

Explanation:

Remediation:

Question 3 See full question

Which instruction is the most important to give a client who has recently had a skin graft?

You Selected:

 Protect the graft from direct sunlight.

Correct response:

 Protect the graft from direct sunlight.

Explanation:

Remediation:

Question 4 See full question

An occupational nurse is called to treat an employee who experienced a finger injury on a piece of

equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is

bleeding profusely. What should be the nurse's first action?

You Selected:

 Apply pressure to the radial artery of that extremity to decrease bleeding.

Correct response:

 Apply direct pressure to the finger with a clean, dry cloth.

Explanation:

Remediation:

Question 5 See full question

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left

calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty

boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What

most likely caused the client's skin breakdown?

You Selected:

 Sitting in the wheelchair for long periods of time