Which client physiological outcome (goal) is appropriate for a client diagnosed with
skin cancer who has had surgery to remove the lesion?
1. The client will express feelings of fear.
2. The client will ask questions about the diagnosis.
3. The client will state a diminished level of pain.
4. The client will demonstrate care of operative site.
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, 3. The client will state a diminished level of pain.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk
factor for the development of pressure ulcers?
1. Constant perineal moisture.
2. Ability of the clients to reposition themselves.
3. Decreased elasticity of the skin.
4. Impaired cardiovascular perfusion of the periphery.
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1. Constant perineal moisture.
The client with full-thickness burns to 40% of the body, including both legs, is being
transferred from a community hospital to a burn center. Which measure should be
instituted before the transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured.
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4. Adequate peripheral circulation to both feet ensured.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is
scheduled for a fecal diversion operation. The nurse knows that client teaching has
,been effective when the client makes which statement?
1. "This surgery will create a skin flap to cover my wounds."
2. "This surgery will get all the old black tissue out of the wound so it can heal."
3. "The surgery is important to allow oxygen to get to the tissue for healing to
occur."
4. "Stool will come out an opening in my abdomen so it won't get in the sore."
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4. "Stool will come out an opening in my abdomen so it won't get in the
sore."
The client has had a squamous cell carcinoma removed from the lip. Which discharge
instructions should the nurse provide?
1. Notify the HCP if a nonhealing lesion develops around the mouth.
2. Squamous cell carcinoma tumors do not metastasize.
3. Limit foods to liquid or soft consistency for one (1) month.
4. Apply heat to the area for 20 minutes every four (4) hours.
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1. Notify the HCP if a nonhealing lesion develops around the mouth.
The nurse is caring for clients in an outpatient surgery clinic. Which client should be
assessed first?
1. The client scheduled for a skin biopsy who is crying.
2. The client who had surgery three (3) hours ago and is sleeping.
3. The client who needs to void prior to discharge.
4. The client who has received discharge instructions and is ready to go home.
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1. The client scheduled for a skin biopsy who is crying.
The female teacher comes to the school nurse's office and shows the nurse a rash on
her hands. The nurse tells the teacher she has probably contracted impetigo from one
of the students. Which intervention should the nurse implement?
1. Instruct the teacher to go to her HCP today.
2. Tell the teacher to wash her hands with soap and water.
3. Encourage the teacher to rub vitamin E oil on the lesions.
4. Explain that the rash will go away in a few days.
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1. Instruct the teacher to go to her HCP today.
The elderly client is admitted from the long-term care facility diagnosed with
congestive heart failure. The client complains of severe itching on both hands and the
nurse notes wavy, brown, threadlike lesions between the client's fingers. Which
comorbid condition would the nurse suspect the client of having based on these
assessment data?
1. Tinea capitis.
2. Herpes simplex 2.
3. Scabies.
4. Psoriasis.
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skin cancer who has had surgery to remove the lesion?
1. The client will express feelings of fear.
2. The client will ask questions about the diagnosis.
3. The client will state a diminished level of pain.
4. The client will demonstrate care of operative site.
Give this one a try later!
, 3. The client will state a diminished level of pain.
The nurse is caring for clients in a long-term care facility. Which is a modifiable risk
factor for the development of pressure ulcers?
1. Constant perineal moisture.
2. Ability of the clients to reposition themselves.
3. Decreased elasticity of the skin.
4. Impaired cardiovascular perfusion of the periphery.
Give this one a try later!
1. Constant perineal moisture.
The client with full-thickness burns to 40% of the body, including both legs, is being
transferred from a community hospital to a burn center. Which measure should be
instituted before the transfer?
1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured.
Give this one a try later!
4. Adequate peripheral circulation to both feet ensured.
The client diagnosed with stage IV infected pressure ulcers on the coccyx is
scheduled for a fecal diversion operation. The nurse knows that client teaching has
,been effective when the client makes which statement?
1. "This surgery will create a skin flap to cover my wounds."
2. "This surgery will get all the old black tissue out of the wound so it can heal."
3. "The surgery is important to allow oxygen to get to the tissue for healing to
occur."
4. "Stool will come out an opening in my abdomen so it won't get in the sore."
Give this one a try later!
4. "Stool will come out an opening in my abdomen so it won't get in the
sore."
The client has had a squamous cell carcinoma removed from the lip. Which discharge
instructions should the nurse provide?
1. Notify the HCP if a nonhealing lesion develops around the mouth.
2. Squamous cell carcinoma tumors do not metastasize.
3. Limit foods to liquid or soft consistency for one (1) month.
4. Apply heat to the area for 20 minutes every four (4) hours.
Give this one a try later!
1. Notify the HCP if a nonhealing lesion develops around the mouth.
The nurse is caring for clients in an outpatient surgery clinic. Which client should be
assessed first?
1. The client scheduled for a skin biopsy who is crying.
2. The client who had surgery three (3) hours ago and is sleeping.
3. The client who needs to void prior to discharge.
4. The client who has received discharge instructions and is ready to go home.
, Give this one a try later!
1. The client scheduled for a skin biopsy who is crying.
The female teacher comes to the school nurse's office and shows the nurse a rash on
her hands. The nurse tells the teacher she has probably contracted impetigo from one
of the students. Which intervention should the nurse implement?
1. Instruct the teacher to go to her HCP today.
2. Tell the teacher to wash her hands with soap and water.
3. Encourage the teacher to rub vitamin E oil on the lesions.
4. Explain that the rash will go away in a few days.
Give this one a try later!
1. Instruct the teacher to go to her HCP today.
The elderly client is admitted from the long-term care facility diagnosed with
congestive heart failure. The client complains of severe itching on both hands and the
nurse notes wavy, brown, threadlike lesions between the client's fingers. Which
comorbid condition would the nurse suspect the client of having based on these
assessment data?
1. Tinea capitis.
2. Herpes simplex 2.
3. Scabies.
4. Psoriasis.
Give this one a try later!
