NURS 1102 Passpoint-Integumentary – Fairleigh Dickinson University | NURS 1102 Passpoint-Integumentary

NURS 1102 Passpoint-Integumentary – Fairleigh Dickinson University Question 1   See full question When assessing a client who is incontinent for risk for developing a pressure ulcer, the nurse should note which facto ...

NURS 1102 Passpoint-Integumentary – Fairleigh Dickinson University Question 1   See full question 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 Correct response: •  Specialty boots   Explanation:   Remediation: Question 6   See full question A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply. You Selected: •  type 2 diabetes mellitus •  hypertension •  advancing age Correct response: •  advancing age •  type 2 diabetes mellitus •  smoking   Explanation:   Remediation: Question 7   See full question The nurse is aware that, in addition to the rule of nines, which is the most important assessment priority when assessing a client with facial burns? You Selected: •  Checking for airway patency Correct response: •  Checking for airway patency   Explanation:   Remediation: Question 8   See full question A client reports a firm, red nodule with a scaly crust on his back. Which of the following is the best nursing intervention? You Selected: •  Notify the healthcare provider. Correct response: •  Notify the healthcare provider.   Explanation:   Remediation: Question 9   See full question A client with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which of the following actions action should the nurse take? You Selected: •  Assess oxygen saturation using pulse oximetry Correct response: •  Assess oxygen saturation using pulse oximetry   Explanation:   Remediation: Question 10   See full question The registered nurse (RN) is referred to a client’s home when a husband and wife have been confirmed to have scabies. The family asks, “How will we get rid of this?” When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority? You Selected: •  Use hot water throughout wash cycle. Correct response: •  Use hot water throughout wash cycle. Question 1   See full question The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause: You Selected: •  diarrhea. Correct response: •  diarrhea.   Explanation:   Remediation: Question 2   See full question A client arrives at the emergency department after falling in the home. The nurse performing the assessment notes the presence of pediculosis corpus. The client's skin and clothing are dirty. The client reports that his children work and no one has time to assist him with his self-care activities. The nurse should: You Selected: •  Advise the family of the client's accusations. Correct response: •  Contact the nursing supervisor.   Explanation:   Remediation: Question 3   See full question The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: You Selected: •  ensure adequate caloric and protein intake. Correct response: •  ensure adequate caloric and protein intake.   Explanation:   Remediation: Question 4   See full question A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate? You Selected: •  Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure. Correct response: •  Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure.   Explanation:   Remediation: Question 5   See full question To treat a client with acne vulgaris, the physician is most likely to order which topical agent for nightly application? You Selected: •  Tretinoin Correct response: •  Tretinoin   Explanation:   Remediation: Question 6   See full question Which disciplines should be consulted when caring for a client with a stage III heel ulcer? You Selected: •  Occupational therapy and infectious disease Correct response: •  Nutrition support and orthotics   Explanation:   Remediation: Question 7   See full question Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? You Selected: •  use of analgesics as necessary for pain relief Correct response: •  use of analgesics as necessary for pain relief   Explanation:   Remediation: Question 8   See full question A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? You Selected: •  urine output of 30 mL/h Correct response: •  urine output of 30 mL/h   Explanation:   Remediation: Question 9   See full question When educating unlicensed nursing personnel (UAP) about how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by: You Selected: •  proper positioning and moving of the client. Correct response: •  proper positioning and moving of the client.   Explanation:   Remediation: Question 10   See full question At an outpatient clinic, a medical assistant interviews a client and documents the findings. The staff nurse reads the progress notes above and begins planning client care based on which nursing diagnosis? You Selected: •  Fear related to potential diagnosis of malignant melanoma. Correct response: •  Fear related to potential diagnosis of malignant melanoma. Question 1  See full question A triage nurse in the emergency department admits a male 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? Record your answer using a whole number. Your Response: •  36 Correct response: •  36   Explanation:   Remediation: Question 2   See full question While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for: You Selected: •  gastrointestinal ulceration. Correct response: •  gastrointestinal ulceration.   Explanation:   Remediation: Question 3   See full question A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage? You Selected: •  "Apply sunscreen even on overcast days." Correct response: •  "Apply sunscreen even on overcast days."   Explanation:   Remediation: Question 4   See full question While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: You Selected: •  basal cell carcinoma. Correct response: •  melanoma.   Explanation:   Remediation: Question 5   See full question A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used? You Selected: •  To prevent signs of hypovolemic shock and restore circulation Correct response: •  To prevent signs of hypovolemic shock and restore circulation   Explanation:   Remediation: Question 6   See full question The priority nursing diagnosis for a client who has just been admitted to the hospital with burns would be which of the following? You Selected: •  Impaired skin integrity Correct response: •  Impaired skin integrity   Explanation:   Remediation: Question 7   See full question Which of the following information should the nurse include when providing discharge instructions to a client with psoriasis? You Selected: •  Trim fingernails regularly. Correct response: •  Trim fingernails regularly.   Explanation:   Remediation: Question 8   See full question The nurse is reviewing risk factors for malignant melanoma with a group of individuals in a community setting. Which of the following risk factors should the nurse include in his/her instructions? Select all that apply. You Selected: •  Presence of large moles •  Dark complexion •  History of severe sunburn Correct response: •  Freckles •  History of severe sunburn •  Presence of large moles   Explanation:   Remediation: Question 9   See full question The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home? You Selected: •  Placement of fire extinguishers Correct response: •  Use of smoke detectors   Explanation:   Remediation: Question 10   See full question The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot. The client originally scraped the foot on a rock while walking barefoot outside; the scrape became infected and eventually required hospitalization for wound care and several days of IV antibiotics. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse? You Selected: •  “I will take the antibiotics until the redness goes away and my foot feels better.” Correct response: •  “I will take the antibiotics until the redness goes away and my foot feels better.” COMPLETED IN10m 40s CORRECTLY ANSWERED4 of 10 questions • Take a Practice Quiz • See your Overall Performance • See your Quiz History Performance by nursing topic  What's this? Integumentary Disorders  5 quizzes taken 3 Your mastery 7.15 Class average View performance for all nursing topics Answer Key Question 1   See full question A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education? You Selected: •  "On the morning of surgery, I won't use lotions or cosmetics." Correct response: •  "On the morning of the surgery, I can shave my surgical area at home to save time."   Explanation:   Remediation: - - - - - - - - - - - - - - - - - - - - - - - - Question 5   See full question A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? You Selected: •  27% Correct response: •  27%   Explanation:   Remediation: Question 6   See full question While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects: You Selected: •  melanoma. Correct response: •  melanoma.   Explanation:   Remediation: Question 7   See full question The nurse is evaluating the client’s risk for having a pressure sore. Which is the best indicator of risk for the client’s developing a pressure sore? You Selected: •  mobility status Correct response: •  mobility status   Explanation:   Remediation: Question 8   See full question The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. You Selected: •  Request an alternating-pressure mattress. •  Reposition the client every 2 hours. •  Cover with protective dressing. Correct response: •  Cover with protective dressing. •  Reposition the client every 2 hours. •  Request an alternating-pressure mattress.   Explanation:   Remediation: Question 9   See full question The nurse is reviewing risk factors for malignant melanoma with a group of individuals in a community setting. Which of the following risk factors should the nurse include in his/her instructions? Select all that apply. You Selected: •  Freckles •  History of severe sunburn •  Presence of large moles Correct response: •  Freckles •  History of severe sunburn •  Presence of large moles   Explanation:   Remediation: Question 10   See full question A teenager asks advice from a nurse about getting a tattoo. When the nurse is providing education, which statement about tattoos is a common misconception? You Selected: •  Tattoos are easily removed with laser surgery. Correct response: •  Tattoos are easily removed with laser surgery. Question 1   See full question A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing? You Selected: •  The dressing should keep the wound moist. Correct response: •  The dressing should keep the wound moist.   Explanation:   Remediation: Question 2   See full question A nurse has noticed an increase in the development of pressure ulcers on the nursing unit. Given the seriousness of the matter, what should the nurse do first? You Selected: •  Formally report her concerns to the nurse-manager. Correct response: •  Formally report her concerns to the nurse-manager.   Explanation:   Remediation: Question 3   See full question A client is receiving fluid replacement with lactated Ringer’s after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: You Selected: •  IV rate increase Correct response: •  IV rate increase   Explanation:   Remediation: Question 4   See full question A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? You Selected: •  Develop a written, individual turning schedule. Correct response: •  Develop a written, individual turning schedule.   Explanation:   Remediation: Question 5   See full question A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? You Selected: •  Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution. Correct response: •  Cover the protruding internal organs with sterile gauze, moistened with sterile saline solution.   Explanation:   Remediation: Question 6   See full question The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care? You Selected: •  Place the client on a pressure redistribution bed. Correct response: •  Place the client on a pressure redistribution bed.   Explanation:   Remediation: Question 7   See full question A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client’s body. Using the “rule of nines,” estimate what percentage of the client’s body surface has been burned. You Selected: •  45% Correct response: •  45%   Explanation:   Remediation: Question 8   See full question The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client’s medical record, the nurse would suspect which of the following medications to be a probable cause of this disorder? You Selected: •  Levothyroxine Correct response: •  Phenytoin   Explanation: Question 9  See full question A client has received burns to the anterior and posterior lower extremities. In order to calculate the expected amount of fluid resuscitation, the nurse calculates the client’s percentage of body area burned as what percent? Record your answer using a whole number. Your Response: •  36 Correct response: •  36   Explanation:   Remediation: Question 10  See full question A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. You Selected: •  Wash hands thoroughly. •  Put on latex gloves. •  Slowly remove the soiled dressing. •  Assess the drainage in the dressing. Correct response: •  Wash hands thoroughly. •  Put on latex gloves. •  Slowly remove the soiled dressing. •  Assess the drainage in the dressing.  Question 1   See full question When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers? You Selected: •  a client who has a decreased serum albumin level Correct response: •  a client who has a decreased serum albumin level   Explanation:   Remediation: Question 2   See full question A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when the nurse applies pressure and observes for color change when pressure is released and the skin color changes to: You Selected: •  reddish. Correct response: •  reddish.   Explanation:   Remediation: Question 3   See full question When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch? You Selected: •  roast beef sandwich, milkshake, and cottage cheese Correct response: •  roast beef sandwich, milkshake, and cottage cheese   Explanation:   Remediation: Question 4   See full question A client comes to the dermatology clinic with numerous skin lesions. Inspection reveals that the lesions are elevated, sharply defined, less than 0.5 cm in diameter, and filled with serous fluid. When documenting these findings, the nurse should use which term to describe the client's lesions? You Selected: •  Vesicles Correct response: •  Vesicles   Explanation:   Remediation: Question 5   See full question A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding? You Selected: •  "I'll eat plenty of fruits and vegetables." Correct response: •  "I'll eat plenty of fruits and vegetables."   Explanation:   Remediation: Question 6   See full question A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? You Selected: •  36% Correct response: •  36%   Explanation:   Remediation: Question 7   See full question Which nutritional deficiency may delay wound healing? You Selected: •  Lack of vitamin E Correct response: •  Lack of vitamin C   Explanation: Question 8   See full question While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at her daughter's home with six other people. During her visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: You Selected: •  "All family members need to be treated." Correct response: •  "All family members need to be treated."   Explanation:   Remediation: Question 9   See full question Which of the following questions is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis? You Selected: •  “Do you have any pets?” Correct response: •  “Do you have any pets?”   Explanation: Question 10   See full question The nurse is assessing an older adult who is living with his son’s family. The client has scald burns on the hands and both forearms (10% first- and second-degree burns). The nurse should first: You Selected: •  Cover the burns with sterile dressing. Correct response: •  Call for transport to a hospital. Question 1   See full question A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate? You Selected: •  Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure. Correct response: •  Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure.   Explanation:   Remediation: Question 2   See full question Which action should the nurse take to provide the most effective emergency care at the accident site for a victim with a heat burn? You Selected: •  Pour cool water over the burned area. Correct response: •  Pour cool water over the burned area.   Explanation:   Remediation: Question 3   See full question A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? You Selected: •  Behind the ears Correct response: •  Behind the ears   Explanation:   Remediation: Question 4   See full question A nurse is conducting a detailed skin assessment on an 80-year-old client. Which finding requires further investigation? You Selected: •  Small, waxy nodule with pearly borders Correct response: •  Small, waxy nodule with pearly borders   Explanation:   Remediation: Question 5   See full question Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy? You Selected: •  a compromised skin graft. Correct response: •  a compromised skin graft.   Explanation:   Remediation: Question 6   See full question Which client should receive a shingles vaccine? A client who: You Selected: •  is older than 60 years. Correct response: •  is older than 60 years.   Explanation:   Remediation: Question 7   See full question 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. You Selected: •  Perform range-of-motion exercises. •  Encourage the client to eat a well-balanced diet. •  Reposition the client every 2 hours. Correct response: •  Reposition the client every 2 hours. •  Perform range-of-motion exercises. •  Encourage the client to eat a well-balanced diet.   Explanation:   Remediation: Question 8   See full question The nurse is teaching a small community group regarding methods to decrease the risk of burns. What is the priority method to decrease burn risks in the home? You Selected: •  Use of smoke detectors Correct response: •  Use of smoke detectors   Explanation:   Remediation: Question 9   See full question A nurse assesses wound evicsceration in a client that had abdominal surgery. In what position should the nurse place the client? You Selected: •  Feet elevated, semi-Fowler’s Correct response: •  Knees flexed, supine   Explanation:   Remediation: Question 10   See full question Which is the best nursing response to make when a client asks why, three weeks after abdominal surgery, there are small lumps under the suture line of the incision? You Selected: •  “The lumps are from the sutures, and will eventually disappear.” Correct response: •  “Those lumps are caused by new tissue growing at different rates.”