PT 3

50問 • 1年前

問題一覧

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immediate intervention by the charge nurse?

The new nurse uses clean gloves when applying antibacterial cream to a burn wound.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Stabilize the cervical spine.

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

Apply water-based cream to burned areas frequently.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best?

"It's true that your life may be different. What concerns you the most?"

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/% TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?

600 mL

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

27%

While assessing a client, a nurse detects a bluish tinge to the clients palms, soles, and mucous membranes. Which action should the nurse take next?

Ask the client about current medications he or she is taking.

A nurse assesses a client who is admitted with inflamed soft-tissue folds around the nail plates. Which question should the nurse ask to elicit useful information about the possible condition?

What do you do for a living?

A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?

What medications are you taking?

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the clients understanding. Which statement indicates the client has a good understanding of this condition?

I can use powder to keep this area dry.

A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the clients skin. How should the nurse document these lesions?

Two 2-cm hyperpigmented patches

While assessing a clients lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next?

Palpate the clients pedal pulses bilaterally.

A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been to church in several weeks because of the discoloration of my skin. How should the nurse respond?

Tell me more about your concerns related to your skin.

A nurse assesses a client who has open lesions. Which action should the nurse take first?

Put on gloves.

A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder?

Clean hair and nails

A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessment should the nurse complete next?

Hemoglobin and hematocrit

During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the clients chest. Which descriptors should the nurse use to document these observations?

Linear and circinate

A nurse assesses an older adult client with the skin disorder shown below: How should the nurse document this finding?

Petechiae

A nurse assesses an older adults skin. Which findings require immediate referral? (Select all that apply.)

Lesion with various colors, Asymmetric 6-mm dark lesion on forehead

A nurse plans care for a client who has a wound that is not healing. Which focused assessments should the nurse complete to develop the clients plan of care? (Select all that apply.)

Height, Alcohol use, Prealbumin laboratory results

A nurse teaches a client to perform total skin self-examinations on a monthly basis. Which statements should the nurse include in this clients teaching? (Select all that apply.)

Look for asymmetry of shape and irregular borders., Assess for color variation within each lesion.

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this clients education?

After you bathe, put lotion on before your skin is totally dry.

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?

A 65-year-old with hemi-paralysis and incontinence

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the clients buttocks, heels, and scapulae. Which action should the nurse take next?

Apply a different pressure-relieving device.

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care?

Change the dressing every 6 hours.

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?

Assess the right leg for pulses, skin color, and temperature.

After educating a caregiver of a home care client, a nurse assesses the caregivers understanding. Which statement indicates that the caregiver needs additional education?

If his tailbone is red and tender in the morning, I will massage it with baby oil.

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching?

High-protein diet with vitamins and mineral supplements

A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection?

Client with a white blood cell count of 23,000/mm3

A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)?

Client admitted from a nursing home with furuncles and folliculitis

After teaching a client how to care for a furuncle in the axilla, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?

I'll cleanse the area prior to applying antibiotic cream.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take?

Place the client in a single room.

A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond?

You can use tap water instead of sterile saline to clean your wound.

After teaching a client who has psoriasis, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching?

I have to make sure I keep my lesions covered, so I do not spread this to others.

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first?

Irregular blue mole with white specks on the lower leg

A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take?

Assess the IV site at least every 2 hours for thrombophlebitis.

A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy?

Which method of contraception are you using?

A nurse caresfor clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?

Fungal infection Ketoconazole (Nizoral)

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?

Recent wound assessment, including size and appearance

A nurse assesses a client who has psoriasis. Which action should the nurse take first?

Shake the clients hand and introduce self.

A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment?

How are you coping with providing this care?

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client?

Punch skin biopsy

A nurse evaluates the following data in a clients chart: Based on this information, which action should the nurse take?

Request a dietary consult.

A nurse evaluates the following data in a clients chart: Based on this information, which action should the nurse take first?

Contact the provider and express concerns related to the wound treatment prescribed

A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.)

Client with a left heel ulcer with slight necrosis Whirlpool treatments, Client with an eschar-covered sacral ulcer Surgical dbridement

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? (Select all that apply.)

Place a small pillow between bony surfaces., Use a lift sheet to assist with re-positioning., Keep the clients heels off the bed surfaces.

A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.)

Assess staff for a history of or vaccination for chickenpox., Check the admission orders for analgesia., Ensure that gloves are available in the room.

A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)

Use a lift sheet when moving the client in bed., Avoid tape when applying dressings., Implement pressure-relieving devices.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this clients psoriatic lesions? (Select all that apply.)

Have you been under a lot of stress lately?, Have you recently had any other health problems?, Have you changed any medications recently?

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.)

Wash your hands before touching the client., Wear gloves when bathing the client.

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ユーザ名非公開 · 61問 · 1年前

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