PT 2

50問 • 1年前

問題一覧

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

Administer patch testing to a patient with allergic dermatitis., Apply a sterile dressing after the health care provider excises a mole.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?

Try to stay out of the direct sun between the hours of 10 AM and 2 PM.

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?

Use a sunscreen with a high SPF when exposed to the sun.

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?

Minimizing sun exposure reduces risk for future BCC.

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?

Prepare the patient for a skin biopsy.

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?

The patient uses a tanning booth weekly.

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?

Clean the infected areas with soap and water.

The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time?

"Are you taking any medications?"

A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance

Papular, wheal-like lesions with white deposits on the hair shaft

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions?

"Your cheek area will be eroded and it will take several weeks to heal."

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?

Thinning of the affected skin

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?

Have the patient use protective eyewear while receiving PUVA.

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?

Surgical excision

Which information will the nurse include when teaching an older patient about skin care?

Use warm water and a moisturizing soap when bathing.

What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?

Wash hands and properly dispose of soiled dressings.

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?

The patient uses bacitracin-neomycin-polymyxin on minor abrasions.

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 most important action?

Consult with the health care provider about the need for further diagnostic testing.

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?

Teach the use of cold packs to reduce bruising and swelling.

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?

"If the medication burns when I apply it, I will wipe it off."

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?

The patient applies a thick layer of the cream to the affected skin.

The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?

Cleaning the skin with antimicrobial soap

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?

The skin around the incision is pale and cold when palpated.

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?

Ask the patient to describe the impact of psoriasis on quality of life.

The nurse working in the dermatology clinic assesses a young adult female patient who has. severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin ?

The patient recently had an intrauterine device removed.

There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening?

38-year old with a 7-mm nevus on the face that has recently become darker

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 (select all that apply)?

Cool, wet cloths or compresses can be used to reduce itching., Take cool or tepid baths several times daily to decrease itching., Use of an over-the-counter (OTC) antihistamine can reduce scratching.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

Full-thickness skin destruction

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority?

Increasing the rate of the ordered IV solution.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Notify the health care provider and prepare for endotracheal intubation.

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?

938 mL/hr

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

Insert a feeding tube and initiate enteral feedings.

While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination?

Wear gown, cap, mask, and gloves during care.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?

Elevate the right arm and hand on pillows and extend the fingers.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first?

Notify the health care provider.

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?

Stool occult blood

Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns?

hydromorphone (Dilaudid)

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient best indicates that the problem is resolving?

"Do you think dark beige makeup will cover this scar?"

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best support maintaining kidney function?

Continue to measure the urine output.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

Vanilla milkshake

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

Extremity movement

An employee spills industrial acids on both arms and legs at work. What action should the occupational health nurse take first?

Remove nonadherent clothing and wristwatch.

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

Use pulse oximetry to check oxygen saturation.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Auscultate the patient's lung sounds.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Place on heart monitor.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider?

Urine output of 41 mL over past 2 hours.

Which patient should the nurse assess first?

A patient with smoke inhalation who has wheezes and altered mental status

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit?

A patient who has a weight loss of 15% from admission and will have enteral feedings started

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?

Place the patient on 100% O2 using a nonrebreather mask.

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

Serum potassium of 6.1 mEq/L

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